Women admitted to psychiatry wards experience high levels of violence and sexual assaults, according to a report released this week by the Victorian Mental Illness Alliance Council.

Across the nine different psychiatry hospital wards surveyed in Victoria, 85% of female inpatients felt unsafe during hospitalisation, 67% reported experiencing sexual or other forms of harassment and 45% of respondents had experienced sexual assault during an in-patient admission.

The report further described that when the women patients reported the incidents, 82% found the nurses to be “not at all helpful”.

The report reveals two major areas of concern – first, that violence against women patients occurs commonly and second, that the incidents are not appropriately dealt with.

Mixed-gender wards

Prior to the 1960s, it was customary for men and women patients to be managed in separate psychiatry wards. Inpatient admissions were often for several months to years.

Since the 1960s, psychiatric inpatient units in many parts of the western world housed male and female patients together. The rationale for mixed gender wards was to mimic “normal” society as much as possible, since the psychiatry institutions became the patients’ world for many years.

Deinstitutionalisation occurred in the 1990s in Victoria, with the mainstreaming of psychiatry wards into general hospitals and closure of the institutions. Psychiatric patients were managed in the community, with short stay admissions to psychiatry wards if required. On average, patients had two to three weeks of hospitalisation in mixed-gender wards.

This rapid turnover of patients and preference for community treatment has meant that hospital wards now treat acutely and severely unwell people, who cannot be treated in the community.

And the level of illicit drug and alcohol use in the inpatient population, both prior to and during hospitalisation, heightens the level of behavioural disinhibiton in this population.

These combined factors lead to a greater risk of aggression and assault, predominantly against women inpatients, who often already have a history of sexual abuse and other traumas.

UK reforms

In response to escalating assaults in inpatient units, the United Kingdom government adopted a strict policy of gender segregation on psychiatric wards in 2006.

This followed a national audit of violence in inpatient settings, which found one-third (36%) of psychiatric inpatients had experienced, and almost half (46%) had witnessed, violence on their current ward/unit.

Patients and staff had similar perceptions of the most common factors triggering violent behaviour: illicit drug and alcohol issues, staff behaviour, space and overcrowding, medication and treatment, and frustration and boredom.

The UK National Patient Safety Agency, in its audit of violence in the acute psychiatry ward between 2003-2005, specifically examined sexual safety, with 122 incidents relating to sexual safety reported. These included allegations of rape, with the alleged perpetrator (another patient) in 40% of cases and a staff member in 60%; consensual sex; exposure; sexual advances; and touching.

The report does not detail how many incidents involved women, but comment is made that both men and women are vulnerable.

Australia lags behind

Australian governments over the past decade have provided funding to reduce domestic violence and sexual assault in the general community and subsequently developed the Women’s Safety Agenda in 2003.

The latest plan to combat violence against women sets out important programs in primary prevention, white ribbon campaigns, work with Indigenous communities and employment-related policies. But has no mention of action to be taken to prevent violence against women in psychiatric wards.

So why has violence against women in psychiatry wards been ignored?

For many decades, women with severe mental disorders were thought to be “too unreliable” to believe when they told their stories of harassment, assault and rape. Disempowered women patients, often with personal backgrounds of domestic violence, have been subjected to violence within a mental health system that is meant to care for them.

For a long time there was denial of this major issue by overstretched, under-resourced mental health systems, with an endemic culture of passivity about violence against women in psychiatric wards.

Over the past years, we have seen improvement in the reporting systems implemented in mental health services and better management of violence against patients, with some shift in the culture of inpatient units; but it is still not good enough.

Steps to reform

We need to take definitive actions to prevent violence occurring in our psychiatric inpatient units, not just implement mechanisms to report and manage the aftermath of assaults.

Investment in improved building designs of psychiatric wards is urgently needed, with special areas designated for women. Wards should be designed to be safe places of healing, with sensitivity for the traumatic backgrounds of many female patients. Privacy and safety measures can be designed into the structure of existing wards, and new units should be provide an individualised, safe space for each patient.

Importantly, the culture of psychiatry wards needs to change through staff gender-sensitivity training to ensure that the safety and privacy is provided and actively maintained for all patients.

Close monitoring of the situation by the general community and governments will ensure violence in psychiatry units is not tolerated.

The history of psychiatric institutions abounds with shameful stories of abuse and maltreatment of women. It’s time to end violence against women in our present day psychiatry wards and provide the therapeutic environment these women need.

** Jayashri Kulkarni is Professor of Psychiatry at Monash University. 

This article was originally published on The Conversation. A reminder to Croakey readers that TC articles are freely available for republishing under a Creative Commons licence.

Unprecedented progress has been made in reducing maternal and child deaths around the world since 1990, according to a new report from Save the Children.

Nonetheless, the statistics remain shocking.  Of the three million babies who die each year in their first month of life, almost two-thirds are from just ten countries.

Thanks to Joanne Simon-Davies and the Commonwealth Parliamentary Library’s FlagPost blog for allowing republication of this article.

***

Poverty’s terrible toll upon the newborn

Joanne Simon-Davies writes:

Every year three million babies die within the first month of life, with one million dying on the day they are born.

Most babies die from preventable causes such as infections.

Every day, 800 women die during pregnancy or childbirth.

These statistics, released last week, are published in the 14th annual State of the World’s Mothers report by the organisation Save the Children. This FlagPost will show that the new born baby is still the most vulnerable and at risk of dying in both the developing and industrialised nations.

To determine in which country a baby is most likely to survive, Save the Children have caculated their first ever “Birth Day Risk Index” to identify the safest and most dangerous places to be born across 186 countries.

In addition, the report also contains the annual “Mother’s Index” (first published in 2000), which ranks 176 countries using five indicators to determine which countries have the best outcomes for mother and baby, these being:

Maternal health —  lifetime risk of material death
Children’s wellbeing —  under five mortality rate
Educational status — expected years of formal education
Economic status — gross national income per capita
Political status — participation of women in national government

For more information on the methodology, see page 75 of the report.

Below are some of the key findings from the report:

1. The first day of life is the most dangerous for both the mother and her baby; babies born in Somalia has the highest risk of dying on day one (18 deaths per 1 000 live births), followed by Democratic Republic of the Congo, Mali and Sierra Leone (all with 17 deaths per 1 000 live births). A mother in sub-Saharan Africa is 30 times more likely than a mother in an industrialised country to lose a newborn baby at some point in her life. On average, 1 in 6 African mothers are likely to lose a newborn baby.

2. Babies born to mothers living in the greatest poverty face the biggest challenges of survival. Virtually all (98 per cent) of newborn deaths occur in the developing world. Almost two-thirds (65 per cent) of the three million deaths in the first month of life occur in just ten countries:

However, whilst the number of deaths is still very high, according to Save the Children:  “The world has made unprecedented progress since 1990 in reducing maternal and child deaths. Working together, governments, communities, nongovernmental organisations and families have reduced the annual number of children under five who die each year by over 40 per cent — from 12 million to 6.9 million. Progress for mothers has been even greater, with deaths declining almost 50 per cent since 1990 — from 543 000 to 287 000 per year.”

3. Low cost equipment such as antibiotics to treat infection, resuscitation devices to assist with breathing, plus basic education in regards to proper hygiene and breastfeeding along with trained health workers, saves lives of both mothers and babies. According to the report, there is a shortage of five million health workers …. in particular those trained in midwifery skills. Also, 40 million women each year give birth at home without the help of a skilled birth attendant, increasing the risk of death of either the mother or child.

4. In the industrialised world, the USA has the most first-day deaths with an estimated 11 300 babies dying each year (three deaths per 1 000 live births). This compares to two deaths per 1 000 live births in Australia (or 480 deaths per year). Of those countries ranked the highest in the index, all are from industrialised countries with Australia being the only country outside Europe.

Mother’s Index rankings: top ten countries:

1. Finland
2. Sweden
3. Norway
4. Iceland
5. Netherlands
6. Denmark
7. Spain
8. Belgium
9. Germany
10. Australia

Whilst Australia was ranked 10th, this is not shared across the whole population. According to the Australian Bureau of Statistics, infant mortality within the Indigenous population (7.2 per 1 000 live births in 2011) is still much higher compared with the total population (3.8 per 1 000 live births).

Despite overall infant death statistics looking bleak, particularly in developing countries, the report indicates that gains have been made. In Peru, the newborn death rate was 26 per 1 000 live births in 1990; dropping to nine deaths in 2011 (65 per cent decline). Bangladesh has declined by 49 per cent from 52 per 1 000 live births to 26 per 1 000 live births over the same period.

There is further information on the Save the Children report here.

***

Sources

Surviving the First day, State of the world’s mothers, 2013
ABS, Deaths Australia, 2011, Cat no. 3302.0

• This article was first published by the FlagPost blog 

Just when we thought we were heading for a more tolerant and accepting attitude toward people afflicted by mental illness, a feature and a news article in Saturday’s The Australian quoting leaders in the area of forensic psychiatry have revived the old mental-illness-equals-axe-murderer stigma.

One of the articles was based on a recent paper published in the journal Acta Psychiatrica Scandinavica showing a higher rate of conviction for all violent offences by people with psychiatric disorders in Victoria.

The second article examined the random attack of a stranger by a person with mental illness, which research has shown to be a rare event; most violence by mentally ill people is directed toward family and acquaintances.

Both of The Australian’s articles quoted Professor Paul Mullen and Professor James Ogloff of Monash University, who are co-authors of the Acta Psychiatrica Scandinavica study.

In 1984, Mullen wrote a paper that reported no increased risk of violence from people with a mental illness. And his 1997 review reported an increased risk of violent behaviour in a small proportion of patients. He is quoted as saying that new data has changed his views.

The newspaper articles include errors that are very damaging to the mentally ill. First, by using the umbrella term “mental illness”, they suggest that everyone with mental illness is more likely to be violent.

However, there is no increased risk of violence in most of the more common types of mental illness; the risk is almost entirely confined to a small proportion of those patients diagnosed with schizophrenia-related psychosis.

By suggesting that everyone who has a mental illness could possibly be violent (just as you and I), the articles isolate, highlight and stigmatise everyone with a mental illness, from depression and anxiety to most people with psychosis.

Most cases of more serious violence by these patients have occurred because of frightening persecutory beliefs arising from active symptoms of the illness.

The increased risk of violence in people with conditions such asbipolar disorder, on the other hand, is almost entirely due to the effects of substance abuse. And it goes without saying that violence is one of the many things people with anxiety and depression fear.

Rather than being perpetrators of violence, the mentally ill are far more likely to be its victim. This is mainly because of the disability and social disadvantage associated with being mentally ill, but also because these people are forced to associate with a small number of violent patients while in hospital.

Mental health laws in Australia detain patients in hospital after they have been deemed at risk of harm to others, rather than because they need treatment. Indeed, they do not even recognise the need for treatment.

This exposes patients who will never commit an act of violence to assault by the minority of patients who are, in fact, violent. For example, three patients have been killed in the Thomas Embling Hospital in Melbourne in as many years.

But the main omission in the two Australian articles was their failure to point out that most of the psychotic patients who committed acts of violence were not receiving treatment.

Indeed, the more serious the violence, the more likely the patient has never had the experience of remission from symptoms such as hallucinations of voices or false beliefs, or a medical explanation for their symptoms.

People with schizophrenia who are receiving treatment are rarely violent, a fact that is evident from the very low rate of violent offending by conditionally and unconditionally released forensic patients in New South Wales.

Only 12% of non-lethal serious violence by people diagnosed with psychotic illness that were dealt with in the NSW District Court, for instance, were committed by people receiving treatment at the time of their offences.

Rather than the blanket statement that the mentally ill are more violent than other members of the community, the correct conclusion is that while most people with mental illness will never commit an act of violence, people with untreated psychotic illness (and those involved in substance abuse) are more likely than the average person on the street to be seriously violent.

** Olav Nielssen is Senior Lecturer in Psychiatry at the University of New South Wales. He has received speaker’s fees from Astra Zeneca. 

This article was originally published on The Conversation. A reminder to Croakey readers that TC articles are freely available for republishing under a Creative Commons licence.

Here are links to:

• Health and Ageing Budget statements

• A table giving a quick overview of health spends and cuts

• Ministerial press releases

• Closing the Gap press release

• The Treasurer’s speech

***

Overview of key announcements

• $55.7 million over four years to expand BreastScreen Australia’s active recruitment of women in the target range of 50-69 years of age to women 50-74 years of age. From 2013-14, all Australian women 70-74 years of age will be actively invited to undertake free breast screening every two years – a first for the program. This will improve the early detection of breast cancer, resulting in more than 145,000 additional women screened every two years from 2016-17, with up to an additional 1,170 breast cancers detected every two years.

• The target age range for the National Bowel Cancer Screening program has also been extended, and from 1 July 2013, people turning 60 will be invited to undertake free bowel cancer screening through the program. This will build on the current program, which invites those turning 50, 55 and 65 years of age to participate in screening. From 1 July 2015, people turning 70 will also be included in the program. Around 5 million Australians will be offered free screening over the next four years. The 2013-14 Budget commits $16.1 million over four years to ensure that the program is available to all eligible Australians.

Clarification from Bowel Cancer Australia:

Bowel Cancer Australia would like to clarify some media reports regarding the budget announcement relating to the Government’s National Bowel Cancer Screening Program (NBCSP).

Additional funding for the National Bowel Cancer Screening Program (NBCSP) in the 2013-14 budget is $3.7 million for program reporting.

No new ages for the National Bowel Cancer Screening Program (NBCSP) were announced in this budget. The addition of 60 and 70 year olds were announced in last year’s budget.

In 2013, the National Bowel Cancer Screening Program (NBCSP) is only relevant to people aged 50, 55, 60 and 65, not all Australians aged over 50. It remains a five yearly screening program despite medical guidelines recommending screening for people aged 50 and over every one to two years.

The $16.1 million allocation to the National Bowel Cancer Screening Program (NBCSP) is over four years and relates to health professional reporting of the program.

A ‘fully implemented’ bowel cancer screening program (two yearly screening for people aged 50-74) is still scheduled for 2034, as per last year’s budget announcement.

(Croakey’s wording was taken from Budget papers.)

• $4.1 billion for a dental reform package, in addition to the $515.3 million investment in dental health made in the 2012-13 Budget.

• From 1 January 2014, around 3.4 million children aged 2-17, in families who meet a means test, will be able to access up to $1,000 worth of basic essential dental treatment capped over a two year period under the Grow Up Smiling program. This replaces the teen dental program. A National Partnership Agreement to expand services for adults in the public dental system will commence on 1 July 2014.

• A Flexible Grants Program will commence in 2014 to provide funding for dental infrastructure in outer metropolitan, rural and regional areas.

• Two industry funded clinical quality registers will also be established with $5.1 million over two years in initial Government funding. These will enhance national post-market surveillance for high risk implantable devices such as pace makers and breast implants, so that potential faults with devices can be detected more quickly and followed up appropriately. There will also be enhanced patient contact arrangements for patients with high-risk implantable medical devices. In the event of a recall of a device, hospitals will follow a new national protocol to contact affected patients.

• A National Antimicrobial Resistance (AMR) Prevention and Containment Strategy will provide national and international leadership on this significant global health priority. The Strategy will also coordinate Australia’s efforts across human and animal health to reduce, monitor and respond to AMR. The Government will expand surveillance of AMR and antibiotic usage; implement infection prevention and control activities to reduce the spread of infection in general and of resistant infections in particular; and implement antimicrobial stewardship programs to provide a systematic approach to optimising the use of antibiotics in primary health care, residential aged care facilities and hospitals.

• There will be a review of the drug and alcohol prevention and treatment services sector to clarify the range of services currently funded; develop common understanding amongst governments and the sector of current and future service needs; and clarify the type and timing of drug and alcohol funding activities undertaken by governments. The review will be concluded in 2014 and its findings will inform the next funding round under the Substance Misuse Service Delivery Grants Fund scheduled to commence in late 2014.

• Reviews of Medicare Benefits Schedule (MBS) items – 16 reviews that are now underway will be progressed, and a further two specialty reviews will be undertaken (does anyone know what they are for??), “to ensure that items listed on the MBS remain clinically relevant and consistent with best practice”.

• This is the one that will have the medical lobby screaming: Changes to MBS indexation so that MBS fees will be indexed on July 1 each year (in line with many other programs) rather than on November 1. The next indexation date will be July 1, 2014.  Savings will also come from removal of double billing under Chronic Disease Management , and an increase of  the upper (general) threshold of the extended Medicare safety net to $2,000 from 2015. These measures will save $889.4 million over four years. (Update 16 May: For a more detailed explanation of these changes, see the Commonwealth Parliamentary Library’s article.)

• More cuts ($20 million over four years) are to come from the National Rural and Remote Health Infrastructure Program, and $10.8 million will be saved from not proceeding with Katherine and Gove District Hospitals.

• $80 million will be cut from Health Workforce Australia’s budget over four years (you can get a sense of the breadth of HWA’s work here.) HWA sources say that the first $20 million cut next financial year is likely to come from savings in the Clinical Training Funding (CTF)  program and the International Health Professionals (IHP) program. Reaction added: Former HWA board member, Professor Andrew Wilson, director of the Menzies Centre for Health Policy, University of Sydney: “It would be very unfortunate if the reduction in HWA funding impacted on its support for initiatives to make the increased number of clinical graduates work ready. It would be unfortunate if it also impacted on the programs to reform health workforce training. However, while this is a large reduction I think the Board will could make changes that will maintain its priority programs.”

• In 2013-14 there will be a new Medicare Locals Accreditation Scheme to support Medicare Locals to meet best practice organisational management and service delivery processes. Accreditation is one aspect of a broader quality framework for Medicare Locals, which will seek to promote transparency, information sharing, and a culture of continuous quality improvement. Work will continue on the National Evaluation of Medicare Locals to assess the extent to which Medicare Locals are progressing toward the five strategic objectives of the program.

• A National Primary Health Care Strategic Framework has been agreed and the Department will work with the states and territories to develop bilateral plans for primary health care by July 2013.

• In 2013-14, the NPS will complete the first phase of the development of the MedicineInsight project and deliver to the Australian Government the first reports from this dataset. The NPS is developing the MedicineInsight project to capture, store and analyse GP data to better inform how medicines are being used in clinical practice.

• Safety and quality initiatives will aim to reduce unnecessary clinical variation in the use of blood products, reduce unnecessary radiation exposure from diagnostic imaging and develop an Annual Atlas that identifies unwarranted clinical variation.

• The Mental Health Nurse Incentive Program, which provides access to coordinated clinical care for patients with severe and persistent mental health disorders in the primary care setting, will continue under existing arrangements pending a restructuring in response to an evaluation published late last year. This will enable community based general practices, private psychiatric practices and other similar organisations to continue existing arrangements with mental health nurses.

• The Budget also includes funding for perinatal depression initiatves, the Partners in Recovery initiative, headspace program for teenagers and young adults, and expansion of the Access to Allied Psychological Services (ATAPS) program, which  funds Medicare Locals to broker allied mental health professionals to provide psychological treatment to people with a diagnosed mental disorder. The expansion targets hard to reach groups and communities that are currently underserviced, such as children, Aboriginal and Torres Strait Islander communities and socio-economically disadvantaged communities.

• From 1 July 2013, the My Aged Care website and call centre – key components of the new Aged Care Gateway – will be established. This will provide older people, their families and carers with access to the information they need, and enable them to more easily navigate the aged care system.

• The  Closing the Gap release says the Government is investing $6.5 million over three years to 30 June 2016 to continue to support Indigenous communities to participate in the digital economy and access  government services online. The agreement supports the ongoing operation and maintenance of public internet facilities delivered under the original agreement and provides training to Indigenous people in the use of online technology

• Funding of $16.5 million over four years will improve eye health for around 20,000 Indigenous Australians. The aim is to eliminate trachoma – an infectious eye disease that  can lead to blindness – in affected communities.

• $3.9 million will be spent over four years on mosquito control activities including a program to prevent the spread of mosquito-borne diseases such as dengue fever in the Torres Strait and to the mainland. Funding will also support communication and coordination between Australia and Papua New Guinea to reduce communicable disease risk in the Torres Strait.

•  $15 million over three years from 2014-15 to continue  funding to the National Congress of Australia’s First Peoples. Joint Select Committee on Constitutional Recognition of Aboriginal and Torres Strait. $1.3 million over two years will be provided to support the work of the Joint Select Committee on Constitutional Recognition of Aboriginal and Torres Strait Islander Peoples to establish a parliamentary and community consensus on referendum proposals.

***

Wrap of reaction

The Social Determinants of Health Alliance: Health inequity grows as Senate report gathers dust

The Social Determinants of Health Alliance has expressed disappointment at there not being any mention in this year’s Federal Budget about the shame of increasing rates of health inequity in a country that prides itself on giving everyone a “fair go”. Read the full release here.

***

Public Health Association of Australia: Mixed reaction

The long term plans to underpin Australian children’s education and a National Disability Insurance Scheme are welcomed by the Public Health Association of Australia (PHAA).

Improved health outcomes rely on all Australians having a positive start in life, and that requires a strong and long term government commitment to children’s education.  Similarly, people and families living with disabilities need the assurance of a national insurance scheme to meet their daily needs.

Other public health areas also received support in the 2013/14 budget:  cancer prevention and screening ($4.5m to CanTeen for youth cancer networks; $3.7m increase for the National Bowel Cancer Screening Program; $55.7m over four years to expand breast screening to a wider age range of women); $16.5 million for trachoma prevention and eye health for Indigenous Australians; $1.7m for an OzFoodNet national partnership;  $64.6m for the National Partnership on Preventive health; $11.1m to local government for healthy communities initiatives;  $28.9m for healthy children (0-16 years) initiatives; $24.7m for workplace health programs; and $3.9 million to combat dengue fever and tuberculosis.

Associate Professor Heather Yeatman, President of the Public Health Association of Australia (PHAA), supported the Government’s commitment to funding continued compliance and enforcement activities associated with tobacco plain packaging legislation and $155.2m to treat additional public dental patients.  “It is important that current public health initiatives are not forgotten when large new programs are announced.”

The PHAA acknowledged other important areas in the budget that will support health outcomes in the long term.  These included $777 million for a new National Partnership (NP) on Closing the Gap in Indigenous Health Outcomes, including preventative health checks for Indigenous Australians; funding for key urban public rail projects that will encourage fewer cars on the road; and $300 million over four years to support jobseekers in the transition to work.

The PHAA had suggested that the government could raise much needed funds and achieve improvement in public health through taxes – a volumetric tax on wine, the abolition of the WET rebate and implementation of a tax/levy on selected nutritionally undesirable foods.

“Funds raised by these taxes could be used for preventive programs and to promote and subsidise nutritionally desirable foods for disadvantaged groups” said Professor Yeatman, “but this did not happen.”

***

Meanwhile, the Treasurer’s announcement of changes to the indexation of tobacco excise (expected to add 7 cents to the price of a pack by the first half of next year) did not impress one public health advocate:

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National Rural Health Alliance: Good in parts – like the curate’s egg

Tonight’s Budget has kept faith with four major initiatives which, over time, will help transform Australian society and contribute to good health, including in rural and remote areas.

As expected, there are some significant new investments in cancer care and treatment, but little else to excite those in the health sector.

And disappointingly, no improvements yet to rural health workforce programs.

The four major initiatives are the Gonski education reforms, DisabilityCare Australia, improvements to public dental health services (initially for children and teenagers) and the National Broadband Network.

Although much of the detail relating to the first two is still in their fine print, foundations have been made which will ensure they become realities and so help lay the basis for good health.

If rural schools can be funded according to educational need it should be possible to equalise educational outcomes in rural areas, making a contribution to greater city-country equity in employment, income and health.

DisabilityCare Australia, with the ongoing support of State and Territory Governments and underpinned by the Medicare levy increase, will end the lottery relating to care for people living with a disability – a lottery which those affected in rural and remote areas win even less frequently than those in major cities.

These two major initiatives have been confirmed tonight as areas for significant investment over the next several years. And GUS is very welcome – Grow Up Smiling – which will see the Commonwealth investing in dental care for 2 to 17 year-olds, starting 1 January 2014, part of the dental reform package announced in August 2012.

The fourth, also confirmed in tonight’s Budget, is the Government’s commitment to the National Broadband Network. Like the education and disability reforms, the NBN is a long-term and high cost project which, when fully delivered, will improve health and wellbeing (including through enhanced business opportunities) for people everywhere and give the same chances in a digital world for people in remote, rural and city areas.

The savings measures necessary for underpinning these initiatives include a halving of the allocation to the National Rural and Remote Health Infrastructure program from $10 to $5 million a year. The smaller amount will be focused on remote Indigenous communities and places under 20,000 people.

Those who went to the 12th National Rural Health Conference will be delighted about continued investment in Indigenous eye health. And in what is a credit to its advocates, funding has been uncapped and new money provided for a year for the Mental Health Nurse Incentive Program while it is being redesigned. Major new investments in screening and services for breast, prostate, lung and bowel cancer are also very welcome.

***

ACOSS: Budget secures landmark disability and education reforms, but gaping hole for poorest on allowances remains

ACOSS warmly welcomes the Federal Government’s vision to secure disability care and dental and schools reform and the strengthening of public revenue to secure funding for these and other services, but cannot believe that there is no income relief for the people who are the poorest,” said ACOSS CEO Dr Cassandra Goldie.

“We praise the move by the Treasurer to lock in government expenditure on crucial social reforms such as education and disability care, in some cases for a decade. We have also been strong supporters of the more equitable and effective system for dental care in Australia and that begins with two-thirds of all children in this Budget. These are not only visionary reforms but long overdue,” Dr Goldie said.

“However, we remain deeply concerned at the failure to reduce the rate of poverty in Australia by increasing the single rate of Newstart and other allowances. While we welcome the modest easing of income rates for people on Newstart and other allowances, the Government has failed to assist the four-fifths of Allowance recipients who are unable to obtain paid work. Each year we fail to act, this gaping hole in our safety net grows. One in eight people, including one in six children, are living in poverty and an increase in the lowest social security payments would have the most immediate and direct impact in reducing it.

“On the savings side, there are some incredibly important measures in this Budget. In addition to the welcome increase in the Medicare levy to fund DisabilityCare Australia, we are pleased that the Budget makes significant inroads into closing tax loopholes and inefficient tax arrangements. With tax receipts down by over $20 billion from the pre-GFC period, we must pull back from generous tax breaks that are not delivering on policy outcomes and eroding our tax base. ACOSS advocated the extension of the Medicare Safety Net threshold, the abolition of the medical expenses tax offset, the capping of self-education expense deductions and the tightening of the thin capitalisation rules, all of which we welcome in this Budget.

“We are also pleased that there is greater investment in tackling tax evasion through trusts. We would have liked to have seen changes to tax rules as well, but hope this commences the reforms needed to close this glaring tax loophole.

“We welcome the integrating of the baby bonus into the family payments system so that it is better targeted but remain concerned about reductions in payments for the poorest families.

“The next step to secure our economic and social progress must be to strengthen revenue. Otherwise we face painful cuts to essential expenditure down the track. Australia is the 5th lowest taxing country in the OECD. If we want a decent safety net, and universal health education and dental services, as well as the housing and infrastructure for present and future generations, we need a sustainable tax base,” Dr Goldie said.

***

The Government’s failure to increase Newstart allowance has been widely condemned, by the UnitingCare Australia and others:

***

Oxfam disappointed on aid funding

The Gillard Government’s latest broken promise on growing the overseas aid program will have a devastating impact on the world’s poorest people, reducing Australia’s aid commitment by $1.9 billion, Oxfam Australia said today.

In response to tonight’s federal budget, the international aid agency also said it was deeply disappointing to see the government plunder another $375 million from the overseas aid program to pay for its domestic asylum seeker policy.

Oxfam Australia Chief Executive Dr Helen Szoke said that the good news this year with aid levels rising from 0.35 to 0.37 per cent was overshadowed by the government’s decision to again delay, by one year, its pledge to grow the overseas aid budget to 0.5 per cent of national income.

“This decision will cost approximately 1.9 billion to our fight against global poverty,” said Dr Szoke.

“That’s $1.9 billion that would otherwise have been spent in some of the world’s poorest countries, making sure children can go to school, that families have enough food to eat, and communities can access safe drinking water.”

On top of previous delays to meeting the 0.5 per cent aid spending target, Australia’s aid effort has been reduced by a total of approximately $4.8 billion since the 2011-12 federal budget.

“This government has failed the world’s poorest people. Every dollar denied has real impacts for people living in poverty,” Dr Szoke said.

“We know Australian aid helps to save lives and improve opportunities for some of the world’s most vulnerable people.

“Last financial year, Australian aid helped more than one million people in Africa access safe water and ensured more than 135,000 pregnant women in East Asia gave birth with the support of a skilled birth attendant.

Dr Szoke also said the diversion of $375 million from the overseas aid program to pay for onshore asylum seeker costs meant Australia would be the third largest recipient of its own aid, behind Indonesia and Papua New Guinea.

“We are fortunate in Australia that we can afford to help those in need at home, as well as provide life-saving aid to those beyond our borders. Australians expect our overseas aid to be focused on helping poor people overseas, not to prop up the funding of domestic asylum seeker policies.

“The government’s continued raid on the overseas aid program will mean more farmers won’t get the help they need to grow food, more children won’t get the education they need for better jobs, and too many women won’t get the support they need to deliver healthy babies.”

Oxfam is urging the government to show leadership on this issue and ensure investment in the overseas aid program gets back on track as soon as possible, with no funds diverted to pay for domestic programs.

“Millions of people around the world are depending on Australia’s promise to step up its fight against global hunger and poverty, and with one in eight people still going hungry every day, we cannot afford to wait,” Dr Szoke said.

“Oxfam is now looking to the Coalition to show leadership on this issue and commit to a timeline to increase aid to 0.5 per cent of national income.”

***

Consumers Health Forum: Budget for medicines and cancer but no hip pocket relief

Patients with cancer or needing new medicines will benefit but there is little relief from hip pocket pain in tonight’s budget, says Carol Bennett, CEO of the Consumers Health Forum.

“The heavier costs consumers now face are fuelling the emergence of a two-tiered health system — one for those who can afford to pay and one for those who cannot. Unfortunately, there is a growing number of Australians, particularly the aged and the chronically ill, who are struggling to afford necessary medical treatment,” Ms Bennett said.

“Medicare is already under strain. We expect to see GP bulk billing drop and even greater pressure on doctors to speed up patient consultations..

“CHF has demonstrated the growing burden health care places on families with our recent “Hip Pocket Pain” campaign, showing that Australians pay among the highest out-of-pocket costs in the world, averaging over $1,000 a year..

“The ballooning expense to government and individuals underlines the need for fresh approaches to pay for health care that will result in more effective, targeted treatment and reduced out-of-pockets. We have an ageing population, increased demand and government revenue slowing and to pay simply for patient throughput no longer makes sense, ” Ms Bennett said..

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Catholic Health Australia

Tonight’s Budget largely insulated health from major cuts in spending and provided a welcome boost to cancer services, but it failed to plug gaps in public hospital funding – a gap that risks coming back to haunt the Government in the lead-up to the Federal election.

Catholic Health Australia CEO Martin Laverty said Government efforts to fund important reforms in education and disability care could, in time, improve social determinants of health in a country that is currently burdened by unacceptable levels of health inequity. Thankfully, fears that funding those services could have resulted in larger health funding cuts have not been realised.

“Not too many who work in the health system expected new spending announcements tonight. Funding increases in cancer screening, research and support is welcomed. Expanded funding for prostate cancer programs at the Kinghorn Cancer Centre at Sydney’s St Vincent’s Hospital campus is most welcome,” Mr Laverty said.

“There is also relief that in an effort to avoid a larger Budget deficit and fund education and disability care, cuts to health programs have not gone deeper. Tonight really could have been a lot worse than it is.”

Mr Laverty said three main health program funding cuts detailed in tonight’s Budget papers will need further attention in the lead up to the election.

“The first funding cut was announced late last year, when the Federal Government clawed back $1.6 billion in public hospital funding over the next four years. Tonight’s Budget only affirms the restoration of this year’s $107 million in funding for Victoria, ignoring need in other states.

“In the coming weeks, public hospitals across every state will have to start announcing service cuts in response to the $1.6 billion public hospital clawback, which a Senate Inquiry called ‘extraordinary and indefensible’. Tonight was a lost opportunity, and this funding should have been restored.

“No one should underestimate how problematic this public hospital funding cut is likely to be in the years ahead. As state and territory governments announce their budgets in coming weeks, we can expect to see public hospital services starting to be wound back.

“Tonight’s second cut involves changes to the Medicare Benefit Schedule that will see a freeze in Medicare payments to doctors. The Department of Health and Ageing confirmed tonight no modelling had been done on how this might impact consumer out-of-pocket costs.

“The third cut will see $80 million taken from Health Workforce Australia over the next four years. The Department of Health and Ageing again confirmed tonight that it’s not known what health workforce programs will be cut as a result of a funding clawback, but we do know that severe health workforce shortages are predicted in the years ahead,” Mr Laverty concluded.

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The Australian College of Mental Health Nurses

The Australian College of Mental Health Nurses (ACMHN) welcomes the modest increase to the Mental Health Nurse Incentive Program (MHNIP). The Federal Budget 2013-14 provided $23.8 million in additional funding for the MHNIP.

Minister Butler also re-affirmed the Government’s commitment to working with stakeholders to improve the Program and provide better support to this vulnerable client group.

“It is clear our calls have not fallen on deaf ears and we are delighted with this modest increase in funding”, said Adj Associate Professor Kim Ryan, CEO of the Australian College of Mental Health Nurses. “I look forward to meeting with the Minister to find out how that increase will be implemented”.

And some more mental health reaction:

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Rural Doctors Association of Australia: Mixed budget for rural patients

The Rural Doctors Association of Australia (RDAA) says, for rural Australians and particularly rural patients, this year’s federal budget is firmly a case of the good, the bad and the ugly. RDAA President, Dr Sheilagh Cronin, said:

On the good side, we are pleased to see:

• additional funding for Indigenous healthcare under the Close the Gap initiative
• funding for breast screening for women aged 70-74 years
• significantly more funding for cancer research, treatment and support
• a commitment from the Federal Government that funding under the National Rural and Remote Health Infrastructure Program, while being reduced in actual terms, will see remote areas and Indigenous communities being the priority areas for the remaining funding
• a $20 million increase in funding for the General Practice Rural Incentives Program (GPRIP), however whether this additional funding is allocated to doctors moving to small rural and remote towns is, RDAA believes, dependent on adjustments being made to the ASGC-RA classification scheme.

On the bad side, we are very disappointed that:

• there has been no commitment from the Government to fix the troubled Australian Standard Geographical Classification – Remoteness Areas (ASGC-RA) scheme in consultation with key rural stakeholders, despite the fact that the current system is making it very difficult to attract and retain doctors in many small rural towns
• there has been no commitment to introduce a National Advanced Rural Training Program or additional supports to provide a ‘pipeline to rural practice’ for the many young doctors now graduating from Australia’s universities
• there has been no commitment to reverse the $2000 / year tax deduction cap on work-related self education expenses, given a $2000 limit makes it extremely difficult for rural doctors to afford continuing medical education given the costs of course registration, travel, accommodation and locums
• the Medicare Safety Net has been increased to $2000.

And on the ugly side…

• The Federal Government’s decision to cut Medicare rebate funding over four years by $664.3 million (through realignment of Medicare indexation) is of serious concern.

Dr Cronin said: “It will discourage more rural Australians to seek preventative healthcare and health checks, despite the fact this healthcare would save the Government significant future expenditure by reducing chronic disease and hospitalisations.

“And we are significantly concerned that the aged, frail, disabled and those with chronic disease will be worst hit by the rebate funding cut, given they regularly need to access healthcare, as well as low-income rural Australians who simply cannot afford additional healthcare costs…..

“Medicare rebates are, in reality, a subsidy to the patient, not the doctor. If these subsidies to patients don’t keep up with the CPI, then practices will have no choice but to pass on these costs to the majority of their patients, and/or limit the amount of bulk-billing they do. These are the harsh economic realities.”

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AMA: Government targets sick people to reduce Budget deficit

AMA President, Dr Steve Hambleton, said tonight that the Government will force sick people to pay more for their health care to help address the Budget deficit.

Dr Hambleton said that the decision to delay indexation of the Medicare Benefits Schedule (MBS) from 1 November 2013 to 1 July 2014 – which is effectively a freeze on MBS indexation – will rip $664.3 million out of primary health care services.

“The Government is getting sick people to help fix the Budget black hole,” Dr Hambleton said. “People will pay more for their health care every time they visit the doctor. The sicker you are, the more you will pay. Even veterans will be hit. The freeze will hit health services provided by the Department of Veterans Affairs.

“Many families will face further increases to their health care costs through the increase of the upper Medicare Safety Net threshold to $2000. At a time when many Australians are facing huge cost of living pressures, it is going to get harder for people to cover their health care costs. Some people may choose to put off seeing their doctor.”

Dr Hambleton said it is surprising that a day after the Government announced record bulk billing figures, it hands down a package that will force bulk billing rates down.

The AMA welcomes funding in key areas, including:

·        $777 million for Closing the Gap in Indigenous Health Outcomes;

·        the World Leading Cancer Care Package; and

·        a national patient register for high risk implantable devices.

The AMA will closely examine the Budget Papers before making a comprehensive response to the overall Budget across portfolios.

A particular focus will be on the Government’s changes to taxation of work-related self-education expenses, which make it harder for doctors to improve their skills to the benefit of patients.

***

At The Conversation

Hal Swerissen, Professor of Health Policy, La Trobe University, says:

The budget delivers on funding for the NDIS, the government’s major policy initiative. It also includes funding for dental health reform and has there is money for cancer prevention, new pharmaceutical listings, rural incentives program for GPs, and aged care reform.

The budget makes sensible savings by removing double dipping on Medicare by GPs, removing the net medical expense tax offset, increasing the general threshold of extended Medicare Safety Net and realigning of Medicare Benefits Schedule indexation arrangements.

Overall, apart from the NDIS, the budget continues health policy directions already in place. As with social services, significant real growth in the health budget is projected over the forward estimates to deal with population growth, population ageing and health inflation.

Stephen Duckett, Director, Health Program at the Grattan Institute, says:

This budget contains mostly small changes here and there from a health perspective. The funding of DisabilityCare is a major initiative and represents a significant step forward for equity.

The slower indexation of Medicare rebates could result in access problems for consumers if doctors increase their fees ahead of the rebate changes.

This budget does not future proof Australia. A number of decisions have not been taken to eliminate waste from the system, such as addressing the excess prices in the Pharmaceutical Benefits Scheme

There are small increases in highly targeted research programs in cancer and aged care research. The McKeon proposals to prioritise relevant health services research have not been pursued, which is a disappointment.

Also at The Conversation: health equity and the budget.

***

Meanwhile, the Get Up review of the budget notes that over $5 billion in fossil fuel subsidies remain in place.

It is striking that the health portfolio budget statements under “population health” and “biosecurity and emergency response” outcomes do not even mention climate change…

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Updates added on 15 May, 2013

NACCHO: Lack of detail leaves a question mark over Aboriginal health

The $777 million commitment to Close the Gap initiatives in the 2013 Federal Budget is welcome, however the Aboriginal health Community Controlled sector remains concerned about the lack of detail on how and where the money will be spent.

National Aboriginal Community Controlled Health Organisation (NACCHO) Chair, Justin Mohamed, said it was critical that adequate funding was dedicated to support and grow Aboriginal Community Controlled Health services where the biggest gains were being made in improving Aboriginal health.

Download the Aboriginal Health Budget here also see executive summary below

Download Federal Government Press release on Aboriginal spending here

“The lack of clarity in the Budget around how funding will flow to Aboriginal primary Community Controlled Health services is very concerning,” Mr Mohamed said.

“Aboriginal Community Controlled Health services need to be at the forefront of any comprehensive primary health care model.

“It is these services – run by Aboriginal people, for Aboriginal people – that are making the biggest improvements to the health of their communities.

“The Federal Government also needs to put greater effort into getting the states and territories to re-commit to the National Partnership Agreement – due to expire in just over a month.

“It is simply not OK to leave the fate of Aboriginal health hanging while everyone plays politics up to the 11th hour.”

Mr Mohamed said NACCHO was disappointed that the Budget did not spell out how the upcoming National Aboriginal and Torres Strait Islander Health Plan would be funded.

“The Health Plan will not work unless it is properly resourced and after yesterday we are no clearer on how much of the $777 million will be directed to this critical initiative.

“It is also disappointing to again see the focus on Medicare Locals in the Budget. Medicare Locals are yet to prove their effectiveness in the Aboriginal health space where the community controlled model has made positive health gains.

“If we’re serious about closing the appalling gap in life expectancy between Aboriginal and non-Aboriginal Australians, then Aboriginal health needs to be given the attention it deserves and community controlled services better supported.”

Mr Mohamed said NACCHO would be consulting widely with the Aboriginal Community Controlled sector and providing further comment upon further analysis of the budget papers in the coming days.

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Australian Healthcare and Hospitals Association: Some gains but fails to address key issues

The AHHA acknowledges the balanced approach taken by the Government in this year’s Health Budget given the difficult fiscal environment.

The Association welcomes the investment in the suite of initiatives comprising the new cancer package – World Leading Cancer Care – and the further investment in mental health.

However, the Government has failed to address some of the most important issues facing the Australian people.

The Gillard Government has claimed credit for reduced waiting times in emergency departments arising from its investment in sub-acute services.  However with no ongoing commitment to the sub-acute programs the gains achieved will quickly evaporate and pressure will again be directed back onto acute hospitals leading to longer waiting times and poorer outcomes.

The Government has overlooked the opportunity to make a significant commitment to addressing the social determinants of health. The Senate Standing Committee on Community Affairs recently recommended that the Government commit to addressing the social determinants of health and give consideration of the social determinants of health in all relevant policy development activities. This Budget has done nothing to implement those recommendations which are critical to addressing the inequities that exist in health outcomes.

It is extremely disappointing that the Budget includes savings measures that will result in higher out-of-pocket costs for medical services, such as delaying Medicare rebate increases and tightening criteria for the Medicare safety-net.  Australians already face higher out of pocket costs when accessing health care than people in most comparable countries and these measures may widen the disparity.  Despite current high rates of bulk-billing, this will adversely impact on people in areas with poor access to bulk-billed services, particularly those in rural and remote areas who already disadvantaged.

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National Primary Health Care Partnership: A sensible approach to health spending

The National Primary Health Care Partnership (NPHCP) welcomes what it believes is a sensible approach to health spending in last night’s Federal Budget.

NPHCP Chair Damian Mitsch stated that “We largely commend the Government on its health budget announcements. It could have taken a slash and burn approach to help deal with its ominous fiscal outlook, but instead it demonstrated a commitment to addressing some of Australia’s most pressing health needs; maintaining or increasing funding in a number of important areas.”

“The Government’s announcement that it will allocate additional funding to the primary health care nursing, Indigenous health, and rural and remote health workforce sectors, in particular, demonstrates its commitment to reorienting our health system to one that focuses more on prevention and health promotion, and on delivering services closer to where people want them – in their communities.”

The NPHCP believes that in addition to consumer preference, the cost savings associated with strong primary health care cannot be ignored by governments; particularly in the constrained fiscal environment we find ourselves in. “We know that hospital care is the most significant cost burden on our system, and knowing that primary health care works to keep people well and out of hospital, such as through preventative measures and better self-management, then surely investing in it to do its job is smart fiscal policy for any government,” Mr Mitsch said.

The NPHCP is a strong supporter of Medicare Locals in helping to drive this change. “Medicare Locals are providing a much-needed vehicle through which this system reorientation can occur. Many of them are already doing some great things, but more needs to be done, and they must be adequately supported by government to do so. That is why we strongly support the Government’s continued investment in them, and its decision to implement a Medicare Locals Accreditation Scheme. This will help promote value for money by ensuring Medicare Locals are employing best-practice organisational management and service delivery processes when serving their communities”.

***

Doctors Reform Society: Labor doesn’t want patients to see doctors

“The budget announcement that there will be a freeze on rebates for GP services confirms that this Government is not concerned that many Australians delay or don’t see their doctor when they are sick because it costs too much,” said Dr Tracy Schrader, president, Doctors Reform Society.

“Last week Minister Plibersek claimed that the Government’s reforms had led to improved access to GPs and increased bulk billing rates”, said Dr Schrader.

“Now that they are freezing the rebates, doctors will once again move away from bulk billing and patients will pay extra or go without. This hypocritical position by the Government, firstly claiming it is great that bulk billing rates are up and then imposing a freeze on rebates which will make rates go down, needs to be exposed.

“It indicates that the prevailing view of the Government is that the poorest and most disadvantaged Australians should bear the burden for the delayed effects of the global financial crisis”.

“Doctors who want to bulk bill patients because they know that it means patients can afford to see them, will now have to either face an income cut (whilst politicians pay rises continue unchecked despite tough times}, or stop bulk billing and run the risk of dissuading patients who are struggling”.

“Whilst funding for the NDIS, the Gonski reforms, the dental scheme and other smaller but also important projects will all be important for the general health of Australians, the great health reform agenda of this Government has not included any major reforms to address the problem of cost barriers to seeing doctors”, said Dr Schrader.

“Despite the two party consensus that these are economically constrained times the truth is otherwise as we see the gap between rich and poor increase and Australians taxed at lower rates than most western nations.”

“This budget measure is a cynical and hypocritical decision by the party which introduced Medicare nearly 30 years ago. It is hard to recognise as the same party”

***

Mental Health Council of Australia: “A stronger economy, a smarter nation and a fairer society” needs a longer term investment in mental health reform

The Mental Health Council of Australia has described the federal budget as a missed opportunity to continue to build on much needed investment in mental health reform.

“If Australia hopes to achieve the Treasurer’s goal of building “a stronger economy, a smarter nation and a fairer society” then we need a longer term funded plan for investing in mental health reform,” Mental Health Council of Australia CEO Frank Quinlan said.

“We understand that we are living in a tight fiscal environment, but this just underscores the need for a longer term plan for investment and reform. Real fiscal discipline requires spending on the things that matter in the lean years as well as the bountiful years.

“Spending on mental health reform is too important to be dependent on the short term rise and fall of international financial markets and political fortunes.

“The Mental Health Council of Australia is pleased to see that there have been no real cuts to mental health spending, but it is difficult to see how mental health reforms will be sustained without substantial investment every year for the next decade.

“We welcome the inclusion of mental health spending within the NDIS. This investment is genuinely transformative, substantially because it is sustained over such a long period of time.”

“Investments in the Mental Health Nurse Incentive Program, Veteran’s Mental Health, victims of forced adoptions practices, and perinatal mental health are also welcome.”

Following the Budget, the Council asks all sides of politics to commit to long term mental health reform, ensuring a sustained approach for at least the next ten years.

“Australia has not forgotten the optimism and the heady commitments to mental health that were made by both sides of politics in 2010,” Mr Quinlan said. “Australians living with mental illness are still experiencing stigma, are still struggling to find appropriate services and are still falling through the cracks.”

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Palliative Care Australia: A missed opportunity to support Australians at the end of life

Despite predicted growth in the numbers of Australians dying annually, the 2013 Federal Budget has failed to recognise the integral role of palliative care in the health system.

“In the context of the recommendations made in the recent Senate Inquiry into Palliative Care in Australia this Budget is simply disappointing”, said Professor Patsy Yates, President of Palliative Care Australia (PCA). “This has been a missed opportunity to make real improvements in people’s experience of death and dying.”

PCA has long advocated for advance care plans to be included in the Personally Controlled Electronic Health Record (PCEHR) and welcomed last Thursday’s announcement that this work would be funded. This is a significant move forward to ensure that people’s wishes are recorded and recognised, but does not in itself improve end of life care.

“Across the nation health care staff delivering palliative care are losing their jobs. Services are being decimated. Yet there is no money at all for the palliative care workforce in this Budget,” commented Dr Yvonne Luxford, Chief Executive Officer of PCA. “As rates of complex chronic disease increase, the need for a comprehensive palliative care workforce strategy is essential.”

Specialist palliative care is delivered by a multidisciplinary team comprising medical, nursing and allied health staff, working alongside pastoral carers, pharmacists and volunteers.

“If we don’t fund specialist palliative care workforce development now Australians will die without access to the services we need”, warned Dr Luxford. “To be blunt, that means without access to the level of pain management and symptom control that we all expect.”

“Of course, not all people require access to specialist palliative care, but they do need their primary care team to understand the palliative approach. It is simply essential that a significant education program be funded both for the community and all health professionals to ensure that all Australians are well supported as they move towards the end of their life.”

***

Lewis Kaplan CEO General Practice NSW

An issue which will cause annoyance is the new rule that a GP can’t bill Medicare for a standard consult on the same day they bill a chronic disease management plan. This is not helpful to patients who may have difficulty accessing a doctor and need e.g. a small procedure which is not connected to the CDMP and don’t want to have to attend the surgery a second time.   It’s also not helpful to GPs who could have more efficiently seen a patient for more than one reason.   I’d be very surprised if this item is being rorted, rather it’s a good use of GP and patient time. An example of a decision taken in the interests of a backroom Treasury person rather than a front-line health service provider.

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Modest steps in the right direction on ageing and aged care: Hal Kendig, Professor of Ageing and Social Policy, Australian National University

An initial reading of the 2013-2014 Budget suggests that the Government is moving ahead, albeit slowly, with resources for the Living Longer, Living Better (LLLB) reforms and for innovative new directions forthcoming from the Advisory Panel on Positive Ageing.

After the Government launched its LLLB aged care reforms last year, its 2012-2013 budget provided modest initial resources with outlays committed mainly towards building community care towards the end of the four year forward estimates.

The current year budget slowly advances these plans, mainly for expanded home care packages and the My Aged Care website, although later years reduce the previously anticipated growth apparently as part of overall budget trimming.

Valuable but small initiatives related to the Advisory Panel on Positive Ageing include a pilot program to facilitate pensioners downsizing their homes without financial penalties; increased access to broadband internet access; a scoping study on wound management; and a translational research and policy centre to apply evidence to the positive ageing agenda.

These initiatives are on top of significant pension increases mainly for single pensioners over recent years; ongoing increases of health expenditure for all age groups; and initiatives to enable people to work longer.

Overall, major initiatives in ageing, as with other areas, are being left on hold until the years after the Election in a likely difficult fiscal context.  It will be challenging to advance plans for consumer-directed care reforms and entitlement-based care in what already are heavily rationed allocations.

User pays is foreshadowed as part of the answer and this will require careful policy work to ensure equitable access and fair treatment for those with few resources of their own.

In the aftermath of this Budget the Business Council released a well-publicised statement warning about the costs of population ageing ahead.

That is the big picture issue but it is by no means clear that the spectre of ageing can be fairly raised as the major cause of increasing health care and income support costs.

On the contrary, the Positive Ageing Panel raises promising directions for older people to contribute more to the nation’s productivity and to their own support in the context of living longer and an ageing Australia.

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Leading Age Services Australia

Budget 2013 has no real surprises for the age services industry or for health generally. It has been pitched as balancing structural spending with structural saving to support the government reform agenda in a tight fiscal environment.

LASA welcomes a budget with no surprises but laments a lost opportunity to further enhance the reform process by ensuring that funding matches the cost of care for older Australians.

LASA notes that $60.2 million was removed from the workforce compact in line with the 5 March launch of the supplement. $60.2 million removed from direct care of older Australians.

LASA looks forward to being a participant in the research from the Andrew Fisher Applied Policy Research initiative ($4.6M) to enhance positive ageing for all Australians and to enhance the ability of the age services sector to meet the increasing demands of an ageing population.

The removal of $80 million from Health Workforce Australia may adversely affect age services which will need to recruit almost 600,000 workers in the next 30 years.

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Some disappointments from nursing perspectives: Professor Mary Chiarella, Sydney Nursing School, University of Sydney

From a personal big picture perspective: great news about the NDIS, the education funding, the terrific focus on preventive health screening for cancer.

From a nursing perspective, I’m disappointed that they didn’t follow up on the need to boost nursing retention and productivity – the HW2025 study showed that a 20% increase in retention would address the 2025 shortfall almost completely. There are decades of research that demonstrate nurses leave the profession for 2 reasons – 1. because they don’t feel valued or respected and 2. because they are unable to delver the quality of care they were educated to deliver.

Enabling increased productivity has occurred on a minor scale through projects like the MHN scheme, but there were huge opportunities to assist nurses and midwives to work to the full scope of their practice through added MBS support for Nurse Practitioners (NPs) in private practice.

Currently NPs in Australia receive 85% reimbursement of fee for service from Medicare, compared to the 100% received by physicians. NPs in private practice in Australia have access to a limited number of Medicare Benefit Schedule (MBS) items, only four items, compared with physicians who can access many more (Medicare 2010).

These four items are characterised by their length of consultation. For example, a short patient consultation with limited examination and management is valued at $9.20, of which the NP may receive 85%, $7.85. A 40-minute consultation involving extensive history taking and examination and management is valued at $56.30, of which the NP receives $47.90 reimbursement from Medicare (MBS 2013).

For the provision of comparable services, the scheduled fees for General Practitioners are $16.60 and $103.50 respectively, over double the reimbursement of an NP. Greater MBS support for NP services would have been a valuable message for nurses both in terms of recognising their value and increasing their productivity.

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COTA Australia: Welcome initiatives for older Australians but the most vulnerable left wanting

Older Australians will welcome initiatives to improve internet skills, increased action on breast, prostate and bowel  cancer screening, and continued commitment to pension indexing and major aged care reform, said leading seniors advocacy body COTA Australia.

However they will be disappointed the 2013 Federal Budget does little to support the most vulnerable older Australians.

COTA Chief Executive Ian Yates said it was disappointing an increase to the Newstart allowance was not included in this Budget given the fact that a third of long term Newstart beneficiaries are over 55.

“These people struggle for years on Newstart, with many failing to find employment, until they qualify for the Age Pension. The result is many older Australians spiraling below the poverty line,” Mr Yates said.

COTA welcomes the ‘Housing help for older Australians’ pilot which supports pensioners who want to downsize to a more suitable home.   Under the scheme they can put up to $200,000 of the excess sale proceeds from the family home into a special account and the capital and interest will not be counted under the pension income and assets test.

“While a positive step forward the scheme has its limitations,” Ian Yates said “ We welcome any initiative that gives older Australians more freedom to make appropriate lifestyle choices but the pilot scheme has some limitations which will significantly reduce eligibility, so we will be talking to the government about that.

“We would like to see pensioners being able to draw income from these funds to meet the costs of aged care and health services, which is not permitted as the scheme currently stands.

“The scheme doesn’t address one of the most vulnerable group of pensioners, those in the private rental market and at risk of homelessness.  COTA has repeatedly called for an increase in rent assistance and the establishment of a Social Housing Growth Fund to support older Australians in the private rental market many of whom, especially single women, are experiencing significant housing stress.”

COTA Australia supports encouraging older Australians to become more confident with internet technology. “The additional $9.9m for new technology and training grants in the Broadband for Seniors program will encourage further internet use but there should also be help for lower income older Australians to connect the internet to their home, especially with the roll out of the NBN,” Mr Yates said.

“Many pensioners are challenged to afford internet access, not just the initial set up costs but the ongoing service charges. We have been advocating for a broadband supplement for pensioners for some time.”

COTA Australia welcomes investment in collaborative and integrated academic research. “We hope that the establishment of the $4.6m Andrew Fisher Applied Policy Institute for Ageing will provide the opportunity to do just that.

“We want to see research activity that connects the community, the corporate sector and the government with academia to deliver meaningful advice that works for older Australians in the real world beyond their immediate health and aged care needs.”

Mr Yates said older people would also welcome the additional commitments to cancer research and treatment.

“COTA Australia has been advocating for an extension to the age limit of the Breastscreen program for years and we’re delighted that this has been taken up.

“We are also pleased that other cancers that affect mostly older people have been given a priority in the Budget with funding for a new Australian Prostrate Cancer Research Centre and additional funding for the Bowel Screening program which saves many thousands of lives.”

COTA Australia considers the change to the Pension Bonus Scheme as an inevitable part of the winding down of that scheme.

“The Pension Bonus Scheme closed on 20 September 2009 and this change ends the grandfathering arrangements whereby people who qualified before that date have been able to enter scheme. Even then the scheme doesn’t close to these individuals until 1 March 2014.

“We urge everyone who is eligible to enter the scheme to do so in the next nine months.

“COTA welcomes the fact that the Government’s major social policy initiatives for older people have emerged unscathed from a difficult Budget.

“The age pension reforms continue to provide pensioners with unprecedented increases through indexation on top of the major increase in 2009.

“The Living Longer Living Stronger aged care reforms – for which crucial legislation is now before Parliament  – will provide older Australians with more care in the home, more choice and control over services, and a fairer and more sustainable system.”

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Community Services and Health Industry Skills Council: workforce concerns need attention

A driving issue facing the community services and health industry at this time is its capacity to overcome constraints in delivering care, says CEO of Community Services and Health Industry Skills Council (CS&HISC), Rod Cooke.

“And we don’t believe this has been addressed in the 2013 Budget,” Rod Cooke said.

CS&HISC welcomes the Budget’s aged care spending inclusions, and the locked-in commitment to DisabilityCare Australia.

“Both should bring genuine benefits to people across Australia, but the question of who will be providing this support and care continues to go unaddressed,” Mr Cooke said

“The strength of DisabilityCare Australia is undermined by the omission of funding for current and future vocational education and training (VET) qualifications, required to meet the ever expanding and changing Aged Care and Disability services workforce need.

“We’re concerned that the importance of the VET workforce and unpaid carers, that is, the people who will provide the bulk of care, are being undervalued by a decision to not pay more attention to workforce issues,” said Mr Cooke.

“All the good work that’s been put into getting the NDIS and the Aged Care reforms might come undone if the workforce issues associated with the scheme are not integrated now.

Aged care providers and trade unions have been saying for a while now, there’s no way we can enable that sector to cope with the increased pressures of an ageing population unless we undertake a true assessment of how much it actually costs to deliver care now and in a reformed sector,” said Mr Cooke.

“In Aged Care, a nationwide cost of care study would determine what kind of funding figures providers will need to be able to deliver care, sustainably. This is also true for Disability care and support.

“Any cost of care study must take into account all the costs involved with the provision of care, including the true cost of labour – wages, expected pay increases, adjustments in the workforce supplement, and the cost of workforce development, and vocational educating and training.”

The care workforce is predicted to continue to grow faster than any other industry. National data from the Australian Workforce and Productivity Agency (AWPA) states that the health care and social assistance workforce employed almost 1.3 million employees in 2011.

Modest predictions estimate an increase to 1.6 million workers (35 per cent rise) while generous estimates predict a rise to almost 2.1 million (77 per cent) by 2025.

Over 60% of care is delivered by Vocationally Educated and Trained (VET) qualified workers (up to 83% in Aged Care), yet there has been no information released in the Budget as to how Australia will recruit, train and retain a qualified workforce to deliver this care and support.

Despite these figures, Mr Cooke continued, there has been no extra funding allocated to enable the industry’s future workers access to VET qualifications.

“Funding has been earmarked to support up-skilling existing workers and apprenticeships, but there has been nothing mentioned about training new workers to this industry.”

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Australian Medical Students’ Association: Federal Budget lacks vision for future of medical training

The Australian Medical Students’ Association (AMSA) believes the Federal Budget has failed to set out a long-term vision for quality medical education in Australia or for tertiary education generally.

AMSA President, Ben Veness, said the NDIS and the Gonski school reforms are admirable and worthy long-term goals for the Government and the country, but university education should be afforded the same status and support.

“There was some welcome new funding for the university sector in the Budget but nothing of the magnitude to offset the recent huge cuts to higher education,” Mr Veness said.

“The Government has ignored two reviews, that it initiated, which both recommended increased funding for universities, and medical education in particular.

“The Review of Australian Higher Education recommended increased funding for universities. The Higher Education Base Funding Review Panel Report of 2011 found that medical schools were particularly underfunded.

“Medical schools remain underfunded by around $20,000 per student, per year.

“The Government needs to better support universities to provide secure and affordable learning environments for future generations of students, including for medical education.”

“Health Minister Tanya Plibersek has been active in solving medical training pipeline issues through COAG and Health Workforce Australia but she has had to act on a year-by-year and State-by-State basis because of funding uncertainty into the future.

Mr Veness said AMSA welcomes funding for Closing the Gap, cancer care, and DisabilityCare.

“We are disappointed, however, with the delayed increases to foreign aid and failure of the Budget to provide greater support for university students.

“Youth Allowance payments remain well below the Henderson Poverty Line and Start-up Scholarships have been turned into loans that add to student debt and may discourage participation, especially from low socio-economic background students.

“Universities Australia data, released last week, showed that 17 per cent of university students regularly miss meals because they can’t afford them.”

AMSA’s Pre-Budget Submission can be found on its website.

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Some SMH Budget stories that may be of interest 

DisabilityCare news

Health budget news

Universities, students bear brunt of $2.6 billion savings to fund Gonski school reforms

Wrap of Gonksi news

Wrap of climate related news

Paul Smith, political editor at Australian Doctor, has exposed one of the vulnerabilities of the AMA’s campaign with a story about its Queensland branch’s annual conference, to be held at a luxurious venue in Chile.

It would be interesting to know the total value of tax deductions claimed by doctors for such trips every year. A related topic worth investigating is inequities in access to continuing education for the various types of health professionals.

Another issue worth exploring is what the FOAM (Free Open Access Meducation) movement means for the medical conference industry. Are traditional medical conferences losing relevance?

Thanks to Paul Smith for allowing republication of his report below (part one is his original story, followed by AMAQ’s response.)

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AMA’s campaign for tax deductible conference travel stretches to Chile

Paul Smith writes:

The AMA’s campaign against plans to cap tax breaks for medical education has been hit by revelations its Queensland branch will hold its annual conference in Chile at a five-star hotel with “lagoon-style swimming pool”.

The six-day trip to Santiago includes an “air and land” package costing up to $6700 per doctor, with delegates — according to the AMA brochure — staying at the Grand Hyatt, “home to world class, multi-cuisine, restaurants [and] a lagoon-style swimming pool with a waterfall”.

Expected to attract 140 doctors, the September event includes four half-day conference sessions with around 20 hours of medical education on topics such as an “Overview of international health systems and standards — how does Australia stack up?”.

Australian Doctor was told that 30 CPD points — accredited by the RACGP — would be available for GPs who attend.

The Federal Government has been universally savaged over its plans to introduce a $2000 cap on tax deductions for work-related self-education expenses.

Last month, Treasurer Wayne Swan said he wanted to target people claiming tax breaks for “first class travel and five star hotels”.

In response, the AMA warned doctors across all specialities would face significant cost hikes for their medical education under the revamp, which is planned from July next year.

Last week, the AMA released results of an online poll of more than 4200 doctors, which found 98% believed the tax changes proposed by the government would “seriously impair” their professional development as a doctors.

AMA president Dr Steve Hambleton said at the time: “I don’t think the government has thought through the impact of these changes on doctors and a whole range of other professionals who must continually update their skills and knowledge throughout their careers, at their own expense.

“It will create a huge disincentive for doctors to pursue specialised education that benefits the whole community.”

Australian Doctor is seeking comment from AMA Queensland (added at the bottom of this post).

Meanwhile, Unconventional Conventions — a medical education company also running conferences in exotic locations like the Arctic Circle and Mongolia — claims the proposed tax changes could mean an additional cost to doctors of $2000-$6000 to attend some events.

Currently, individual doctors can claim the whole cost of their trip as a tax deduction, typically at a rate of 45%.

Managing director Mark Cunich said his company generally ran seven-day conferences, comprising more than 30 hours of medical content and two days of sightseeing.

But other providers offered 18-day conferences with as little as 12 hours of medical content, he claimed.

“I think that that’s how this issue has come about. People like them are running junkets, basically.” he said.

“Some people call what we do junkets as well, but when we run 30 hours of medical content in a five-day week, others would consider that to be almost a full-time working week.”

Unconventional Conventions co-managing director Margot Cunich said doctors would still opt to travel for their CPD because of the unique experience and peer interaction.

“They find that going to different parts of the world makes them more broad-minded. They like the opportunity we give them to go to local clinics or hospitals and sometimes do a bit of voluntary work, and see how the other system works, see what medical issues there are in other parts of the world.”

AMAQ response

AMA Queensland’s annual conference is planned for 22-28 September 2013 in Santiago, Chile.

The conference theme is ‘Health Worldwide – challenges and directions’ and includes eminent speakers addressing issues such as: how Australia fares in comparison to international health systems, Indigenous and refugee health challenges, Medecins Sans Frontieres operations and opportunities, a PNG Case study and opportunities with Australian Doctors International, primary care for the homeless, medical education at home and abroad etc.

The conference is one of numerous professional development events coordinated by AMA Queensland each year which offer myriad opportunities for medical professionals to further their skills and experience.

The numerous benefits of attending such a medical conference include learning about the latest developments in medicine and health care, engaging with professional peers from Australia and overseas, collectively sharing and discussing ideas, theories and new information, and contributing to AMA policy development among others.

AMA members who attend the conference are self-funded and focused on improving patient care.

The International Baby Food Action Network (IBFAN) says breastmilk contains protective agents and helps children develop a strong immune system. Breastfeeding can mitigate the effects of chemical exposure in the womb, whereas formula feeding does not afford any protection or mitigation.

The IBFAN statement also says formula feeding and industrial baby foods contribute significantly to environmental pollution.

Joy Heads, an experienced midwife and International Board Certified Lactation Consultant in Sydney, gives an overview of the new statement below.

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A useful source of information on breastfeeding and chemical residues

Joy Heads writes:

The reality of the presence of environmental chemicals has been on the world’s radar since the release of Rachel Carson’s book Silent Spring in 1962.

Today it is accepted that every human body contains many man-made chemicals that can cause harm. Human milk has a high proportion of fat and therefore fat soluble contaminants, including dioxins, can be very easily measured.

Expressed breastmilk used to be included in the Australian Basket Market Survey, now called Australian Total Diet Study (ATDS), because it was easy to collect from consenting women in postnatal wards.

Over the last few decades scare tactics have emerged, warning women about the perceived danger of breastfeeding.  I clearly remember one front page headline in a Sydney Sunday paper in the mid 70’s screaming: “DDT’s in breastmilk: mothers poisoning their babies.”

The press coverage of Florence William’s 2012 book: “Breasts: A Natural and Unnatural History”, which covers her investigations into the issue, did little to allay these fears.

It is therefore heartening that the International Baby Food Action Network (IBFAN) has just released “IBFAN Statement on Infant and Young Child Feeding and Chemical Residues” (2013), which presents objective and independent information for parents, carers and health professionals.

The main author of the paper is well respected Dr Adriano Cattaneo, Consultant Epidemiologist and Co-ordinator of the Unit for Health Services Research and International Health, Institute of Child Health “IRCCS Burlo Garofolo”, Trieste, Italy, a WHO Collaborating Centre for Maternal and Child Health. Dr Catteano was an Expert Reviewer on the 2012 NHMRC Infant Feeding Guidelines.

This evidence-based, well referenced statement goes beyond the issue of possible residues in human milk to include that of contaminants in infant formula including in the unnecessary, but cleverly marketed, follow-on formulas, baby foods, feeding bottles and teats.

The paper also emphasises the potential harm of chemical exposure during pregnancy at a time when tissues and organs are growing rapidly. It reinforces the fact that there is now far greater understanding of the beneficial effects of breastfeeding and its role in developing immune protection and mitigating the harmful effects of chemical exposure in the womb.

Conversely, formula feeding does not afford any protection to babies at all. The ecological footprint and consequence of increasing rates of formula feeding is also addressed.

The document lists 10 Key Points and Key IBFAN Messages, which includes the statement that “pregnant and breastfeeding mothers have the right to receive full and unbiased information”.

IBFAN endorses international health regulations to protect, promote and support breastfeeding – because the benefits outweigh any possible harm -“except in the case of industrial disasters and of exceedingly high residues after industrial disasters”.

Contained within the paper is a Call for Action, urging decision-makers and industry across the globe to implement the Stockholm Convention on Persistent Organic Pollutants (POPs).

The Appendix is an excellent reference and carries an analysis of 13 chemical residues or families of chemical residues. IBFAN have considered only substances “for which there is ample literature and that are a target for important policies and regulations worldwide.”

This paper provides strong evidence that the continuing fight for a healthy global environment, with minimum toxins, is a challenging one considering industry redistribution and weak environmental regulations.

• Joy Heads OAM is a midwife and has been an International Board Certified Lactation Consultant since 1986. In 2009, she was awarded the designation of Fellow of the International Lactation Consultants Association (ILCA™). She is currently on the Board of Directors of ILCA, and co-wrote the chapter on “Breast Pathology” for the ILCA’s Core Curriculum for Lactation Consultants. Editors: Mannel B, Martens P J, Walker M. (3nd ed) Jones & Bartlett. MA. USA. 2013.

In 2006 she was awarded the Order of Australian Medal for service to nursing and midwifery as a specialist lactation consultant and to health professional and parent education. Joy was the Clinical Nurse Consultant (Lactation) at the Royal Hospital for Women, Sydney for many years until she retired from paid work in late 2010.

But does the health and medical research sector have its thumbs jammed firmly in its ears?

In the article below, Dr Elizabeth Haworth, Dr Brad Farrant and Fiona Armstrong lament a lack of leadership from the research community on this pressing global public health concern.

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A plea for the health and medical research community to prioritise work on climate change

Elizabeth Haworth, Brad Farrant and Fiona Armstrong write:

The report of the Strategic Review of Health and Medical Research, set up by the Australian Government in 2011 and chaired by Simon McKeon, was released last month, recommending a 10-year strategic plan for the nation.

Despite criticism of the preliminary consultation paper for overlooking the health impacts of climate change, the final report has made minimal mention of these threats to health.

This stands in stark contrast to the 2011 Australian Government Climate Commission report, The Critical Decade: Climate Change and Health.  This report points to increasing frequency and severity of heat waves and other extreme weather events, more infectious and vector-borne diseases and more disease and premature deaths due to air pollutants. It reveals our health services are inadequately prepared for this change and that evidence-based action is urgent.

Ever-increasing scientific evidence and the long-standing consensus of over 97% of climate scientists, the CSIRO, the Australian Academy of Science and every major national scientific body in the industrialised world agree that the planet is warming, that the observed climate change is mostly caused by humans and that business as usual will result in irreversible changes to the climate system.

Worldwide, with less than one degree of the global mean temperature rise, health is already threatened.

The DARA report 2012, commissioned by 20 governments on the human and economic costs of climate change showed that climate change is already a direct cause of 400,000 deaths globally each year, along with 4.5 million deaths annually attributable to urban air pollution and other environmental hazards associated with carbon-intensive economies. The cost of harm from climate change to the world in 2010 alone was $US 1.2 trillion and this is predicted to double by 2030.

Unabated emissions are predicted to deliver an unprecedented four degree global average temperature rise over the next few decades, much faster than previously believed. The Australian summer 2012-13 was declared the hottest on record.

Successful human adaptation to such warming is uncertain.

A recent report from Price Waterhouse Coopers on the rate of decarbonisation required to limit the earth’s mean temperature rise to two degrees found that this would require a sixfold improvement in the current rate of renewable energy uptake and fossil fuel reduction by lowering industrial emissions, effective carbon capture and storage, and stopping deforestation. There are no policies in place in Australia to deliver anything near the required response.

Other countries have innovative approaches to address the health effects of climate change. One good example is the call for pilot projects from the Public Health Institute, to develop models that can be held up, scaled up, and replicated that simultaneously address climate change, community health and health equity. A private Californian investor is funding this initiative.

Unfortunately, in Australia, governments are cutting their climate policies and programs. The federal government has scrapped the contracts for closure program aimed at shutting down some of Australia’s dirtiest coal-fired power plants and is likely to abolish our only intergovernmental body on climate change at COAG.

The Strategic Review of Health and Medical Research failed to comment on the omission of climate change from the National Health and Medical Research Council (NHMRC) priority list for 2013-15.

It acknowledged the need for research into new and emerging health threats from infectious diseases, environmental hazards and changes in the human environment, which may be associated with climate change.

However, it seems to expect the research community to spontaneously take these on to collaborate nationally and internationally and overlap with other chronic disease and mental health research and social determinants of health.

Climate change does and will affect everyone, although its effects may not be recognised on a wide scale until they become devastating.

If the research community, like the Strategic Review of Health and Medical Research, fails to prioritise climate change, the health impacts are likely to overwhelm our health services and research community and we will fail to mitigate because we misunderstand the human threat.

Even when health aspects of climate change were a priority, funding of relevant research by the National Health and Medical Research Council in 2010-12 was only 4% of its total budget.

According to a 2013 study by the Australian Council of Social Service, community services are unable to cope with the demands associated with extreme weather. Increased demand from such events is likely to cause many to collapse.

Despite growing awareness among many Australians about the links between climate change and extreme weather events, there remains a lack of understanding of the scope and scale of implications for human health, health services, the economy and our society.

The Climate and Health Alliance (CAHA) warns that health is and will continue to be harmed primarily by lack of mitigation, but is at risk from a lack of investment in research and preparation of health services to promote the health benefits of and to reduce adverse health effects of climate change.

It recommends that such research should be part of a collaborative global health improvement program in line with the roadmap for applied research in The Lancet in 2009 and the Australian National Adaptation Research Plan – Human Health of the National Climate Change Research Facility.

Given the continuing health threats from climate change, is it reasonable that this national review, tasked with recommending a 10-year strategic plan for the nation, should fail to nominate one of the biggest threats to health as a research priority?

Without support from government and health policy makers, the means must be found to ensure continuing research to limit harm from climate change.

Where will this leadership come from?

In the face of policy paralysis and a lack of political leadership, civil society must step into the policy vacuum to help determine our national direction. But if these calls are not heeded, what then?

Urgent questions are:

• What is the human physiological response to rapid and persistent climate change?
• What are the impacts on people from food and water insecurity, mass global migration, and social and ecological disruption?
• How do we get decision makers to take the health implications of climate change seriously?
• How can we implement scientific and health recommendations to best protect the health of current and future generations from further climate change?

Without earmarked funding, this will be a tough call. Research will have to be integrated into other public health programs and researchers will have to spend a disproportionate amount of time chasing money.

Is this really the intended outcome of the McKeon review?

• Elizabeth Haworth is Senior Clinical Lecturer in Public Health at the University of Oxford and consultant public health physician, now based in Tasmania.

Brad Farrant is a post-doctoral researcher at the Telethon Institute for Child Health Research. He is interested in how ecological factors like biodiversity loss, population growth, peak water and climate change will interact to affect children’s development now and in the future.

Fiona Armstrong is a health and climate policy and communications professional and Convenor of the Climate and Health Alliance.

***

Further reading

• The Guardian reports predictions by Lord Stern that hundreds of millions of people will be displaced from their homelands in the near future as a result of global warming. His warning follows recent news that concentrations of carbon dioxide in our atmosphere had reached a level of 400 parts per million (ppm), as reported here by The Economist.

• At The Conversation, ANU earth and paleo-climate scientist Andrew Glikson writes:

“The land, oceans and biosphere are now in extreme danger, but it doesn’t seem to be driving the global community to the urgent measures required for a meaningful attempt to arrest the current trend. With few exceptions, the accelerating rate of atmospheric CO₂ hardly rates a mention on the pages of the global media, preoccupied as it is with short-term economic forecast, daily exchange rates, share market fluctuations and sports results.

In Australia the language has changed from “the greatest moral issue of our generation” to controversy over a “carbon tax”, diverting the public attention from the climate to a hip-pocket nerve. While we debate the ways to bring about a meaningless 5% reduction in local emissions, we simultaneously develop infrastructure to export hundreds of millions of tons of coal. It all ends up in the same atmosphere…”

• Previous Croakey articles related to climate change and health 

Raise taxation generally (plus specific hikes for tobacco, alcohol, and unhealthy foods), and remove subsidies on the use of fossil fuels. These are among the suggestions from Croakey contributors outlined in the post below.

Contributors also said they’d like to see the Budget bring increased payments to single parents and the unemployed, as a way of reducing health inequalities.

Another suggestion for addressing heath inequalities was to “publish the taxable income and tax paid by all Australian citizens”.

There is also support for having all Government policy and program decisions subjected to Climate Impact Assessment and Health Impact Assessment.

Reflecting widespread support for a health in all policies approach, one contributor suggested that health-based key performance indicators could be introduced for all portfolios.

Croakey contributors also hope the Budget will show a commitment to ongoing health reform, including a “transition away from the small business, fee-for-service model that dominates Medicare now to a capitated model in primary and community care”.

As for how the Government could make savings in health – scrap the private health insurance rebate altogether was the suggestion from some.

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For the compilation post below, Croakey contributors were asked:

1. What is the single most important thing the government could do in the health budget to improve population health?

2. What is the single most important thing the government could do in the overall budget (ie beyond the health portfolio) to improve population health?

3. What is the single most important thing the government could do in the health budget to tackle health inequalities?

4. What is the single most important thing the government could do in the overall budget (ie beyond the health portfolio) to tackle health inequalities?

5. Any advice to the media about how to cover the budget this year? What do you most want to know about it?

6. Where could savings be made in the health portfolio?

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1. What is the single most important thing the government could do in the health budget to improve population health?

Vern Hughes, National Campaign for Consumer-Centred Health Care
Both Labor and Liberal Parties are reliant on corporate donations from alcohol and gaming companies, and in the Liberal Party’s case, tobacco companies as well.

A ban on political donations by corporates to political parties, allowing only donations from individuals, would sever the financial relationship between these parties and the principal suppliers of products harmful to population health. A disinterested policy discussion would then become possible about how to reduce the impacts of these products.

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Reduce the deficit by putting a tax on high salt/fat foods.

Professor Mike Daube, Public Health Advocacy Institute WA
Increase tobacco tax – reduces smoking, reduces inequalities, improves health, provides funding for health and social priorities.

Dr Greg Stewart, President-elect, Australasian Faculty of Public Health Medicine
Put money into strengthening population health expertise in Medicare Locals.

Lyn Morgain, Gail O’Donnell of Healthwest Partnership
Increase funding for evidence based work through the Australian National Preventive Health Agency which will focus effort on both national as well as local / regional campaigns that target particular issues / risk factors in local communities / population groups. Ensure the ANPHA focuses on the community and population level.

Flexibility to deliver different interventions / approaches depending on local priorities to support improved outcomes for local communities.

Reference: Dr Fran Baum is Professor of Public Health at Flinders University. At the Senate Inquiry on the Social Determinants of Health Dr Baum commented:

“while the preventative health agenda does attempt to focus on the causes of disease it is limited by the absence of a national agenda devising strategies to address social determinants of health in a systemic way. The predominant focus on individual ‘lifestyle choices’ and behaviour change as the target of interventions does not adequately address the social context in which behaviours occur, or give sufficient emphasis to the role of health promotion strategies focused on creating healthy settings and development of healthy communities.”

Professor Sabina Knight, Director of the Mt Isa Centre for Rural and Remote Health
Strengthen the critical architecture for reform – the Australian National Preventive Health Agency, The Australian Commission on Safety and Quality in Health Care, Health Workforce Australia Independent Hospital Pricing Authority, National Health Performance Authority

Luke van der Beeke, Managing Director, Marketing for Change
The government needs to ensure that the money available is spent effectively.  That means switching to measuring outcomes, not outputs. I’m a big advocate for policy before politics.

Set some tough outcomes and reach for them.  Don’t set easy to achieve outputs that mean nothing in terms of population health.  For example, let’s take health communications.  You can spend $10m or $20m on a shock campaign on obesity, but if you aren’t changing people’s eating habits its all a complete waste of money. So while I think more money is needed for prevention, the most important thing they can do is ensure the money that’s allocated is used effectively.

And a quick point on social marketing.  The Federal Government talk about social marketing, but they’re not really doing social marketing. They  (and the States) are outsourcing to NGOs or big agencies that are delivering health communication campaigns that look great but change very little.

Success is getting measured by outputs that rarely relate to individual behaviours.  All too often, “success” and the associated measures are about being seen to be doing something rather than ACTUALLY doing something. We need behaviour change. And for that you need real social marketing.

Heather Yeatman, president, Public Health Association of Australia
Funding the development of a National Public Health Policy.

Lewis Kaplan CEO General Practice NSW
Fulfil its commitment to the nation’s health rather than just to the Department of Health and Ageing’s budget and invest in substantial and realistically long-term prevention programs (e.g. diabetes), even if the eventual ‘savings’ accrue to state health departments.

Anonymous medico
Improve vaccination coverage. Serious adverse events are rare, but there should be compensation for any child who has a proven disability because of vaccination. Parents are helping the community by having their children immunised, so the community should provide support if there is a problem. The Disability Care (NDIS) could be the appropriate mechanism.

John Mendoza, mental health advocate, Director, ConNetica Consulting Pty Ltd
The Government has to commit to root and branch reform of Medicare. As numerous independent reports in the past few years have pointed to, the most recent from Centre for Independent Studies and CEDA, Medicare is unsustainable and delivering poor quality care for many, many Australians.

This reform must address map-distribution of providers, access to care, cost of care, quality of care. We must begin to transition away form the small business, fee-for-service model that dominates Medicare now to a capitated model in primary and community care.

Terry Slevin, Cancer Council WA
Expand the National Bowel Cancer Screening program to include a greater number of ages being invited to screen.

Currently with only people turning 50, 55, and 65 being invited, we are missing a rolled gold proven method of reducing deaths from colorectal cancer.  We are also ignoring opportunity to save costs as treating more advanced stage disease is not only less successful but more expensive.

The other thing that is desperately needed is to allow funds to promote the program.  With current participation rates at around 40%, a meaningful investment in an effort to “sell” the benefits of participation would certainly increase participation and therefore the health benefits that are proven to accrue from doing so.

Another is a very modest investment in skin cancer prevention programs. Again another money saver with cost of treatment of preventable skin cancer exceeding the billion dollar mark, here is a case of an ounce of prevention saving pounds (and dollars) of cure.

Linda Shields, professor of nursing – tropical health, James Cook University
Stop thinking that “primary health care” is all about GP clinics. It’s not – it’s about prevention and stopping people getting sick in the first place. Investment in primary healthcare (the real one) would improve the health of all and reduce expensive inpatient costs.

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
The secure funding for preventive services.  There is a big problem here in South Australia, and elsewhere, whereby State governments are focusing their sole attention on acute services and assuming/hoping the Federal government will pick up the costs and mantle of preventive services.

This does not seem to be happening – it’s ‘hoped’ that Medicare Locals will pick up these services, but it doesn’t really seem to be their job either.  If we continue with this extremely shorted-sighted view, we are putting the future health of generations in danger.

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2. What is the single most important thing the government could do in the overall budget (ie beyond health portfolio) to improve population health?

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
For the long term, address climate change by removing the subsidies on the use of fossil fuels.

Professor Mike Daube, Public Health Advocacy Institute WA
Sort out the shambolic alcohol tax system – especially abolishing the Wine Equalisation tax (WET) that enables wine to be sold cheaper than bottled water. Again reduces harms, protects the vulnerable, raises money for other health and social priorities.

Dr Greg Stewart, President-elect, Australasian Faculty of Public Health Medicine
Increase taxation.

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE)
Ensure that the universal nature of Medicare is not undermined by need for increased co-payments, shifts of responsibility for core services to private sector.

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
A comprehensive early childhood strategy, education funding and education system reform (as per Gonski recommendations). Increasing social benefits for unemployed people and single parents.

There has been significant progress in using health impact assessments to understand the effect of program and policy changes across Government on the health system and service costs. This means that a reduction or increase in effort in one part of government / community is understood for the impact that it will have on the broader service and support system. This ‘health in all policies’ approach is the best way to understand the true cost and achieve efficiency in the primary care space and allow a more rigorous approach to policy consideration and program development.

A commitment to the recommendations of the Senate Committee inquiry into the Social Determinants of Health.

Luke van der Beeke, Managing Director, Marketing for Change
Health in All Policies is without a doubt the most important thing the government can do to improve population health.  At present government departments work in silos.

Why not introduce health-based KPI’s for all portfolios?  All of them have significant direct or indirect impacts on population health.  There needs to be a shift in the way we think and talk about health in Australia.

There needs to be a shift in the way we think and talk about health in Australia, and most importantly, a change to WHO talks about health in Australia.  If health practitioners and experts are the only ones talking about health we will never fix public health.

Associate Professor Heather Yeatman, president PHAA
The establishment of an Australian Centre for Disease Control (ACDC).  As a first step the Government must to commission a study to examine the benefits and costs of establishing an ACDC.

The establishment of and requirement for a Climate Impact Assessment and Health Impact Assessment to accompany all Government policy and program decisions (in a similar way to the current requirement for Regulatory Impact Assessments).

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE)
Maintain investment in smoking cessation and mental health and well-being.

Lewis Kaplan, CEO General Practice NSW
Make health in all policies a requirement across all portfolios – eg South Australia.

Anonymous medico
We spend $billions treating diseases resulting from people’s lifestyle choices. While a fat tax would probably be difficult to implement, alcohol is still far too cheap.

John Mendoza, mental health advocate, Director, ConNetica Consulting Pty Ltd
Slash the size of the Federal Bureaucracy. Since 2004, an additional 40,000 people have been employed in the APS. This does not include those now employed in organisations like Medicare Locals. Only about 1 in 4 of the APS actually deliver an end service. The duplication of project management, the inefficiency of the APS has become a high cost factor.

The Federal Government should literally get out of the business of delivering services. It should focus on policy development and setting parameters for delivery.

Second they must wind back all middle class welfare and industry welfare – this adds tens of billions to our nations taxation system.

Linda Shields, professor of nursing – tropical health, James Cook University
Preventing illness in the first place would save heaps of money down the track. A very good investment.

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
To work on joined-up government to tackle the social determinants of health.  There is evidence globally, and locally, of the benefits of Health in All Policies in terms of illness prevention, health promotion and overall health gains.

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3. What is the single most important thing the government could do in the health budget to tackle health inequalities?

Vern Hughes, National Campaign for Consumer-Centred Health Care
There is no quick fix for health inequalities, which are a product of social and economic well-being. The single most useful thing the government can do in the health debate is state this publicly.

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Improve the Newstart payment.

Associate Professor Mark Wenitong, Public Health Medical Advisor
Apunipima Cape York Health Council, School of Public Health, Tropical Medicine and Rehabilitation Sciences, 
James Cook University, Cairns
Understanding the synergies between health and social portfolios re Aboriginal and Torres Strait Islander health inequalities, and thinking about “bundling” program funding (across FACSIA/DOHA eg) to address early childhood/family functioning support and health in a prevention sense.

We also need to have a more sophisticated understanding of health $ investment for long-term health outcomes vs GFC pushed “corporate health” approaches to efficiency.

We need to measure efficiency against a human capability framework, rather than “efficiency” driven by the accountancy consultants (ie KPMG PwC E&Y etc that are basically accountants, hence an inbuilt bias towards fiscal efficiency) – that do ALL of the scoping for DoHA.

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
Provision of funding through improved local service delivery to target populations and geographies where particularly poor health outcomes exist.  A move away from waiting until an acute service response is required (surgery or emergency department) and towards community based primary care.

Targeting intergenerational poverty through a focus on child health.  A comprehensive early childhood health and wellbeing strategy combined with a social protection system would be a positive step towards addressing social and health inequalities.

Luke van der Beeke Managing Director, Marketing for Change
To tackle any issue it needs to be taken seriously.  The Federal government needs to commit to action on tackling health inequalities.

Associate Professor Heather Yeatman, president PHAA
Invest in building the competence and capacity of a national preventative health workforce who understand inequity and the social and economic determinants of health and are skilled to effectively deliver preventive health services at the local level.

Maintaining the funding of Medicare Locals, Locals and Women’s Health at a level that will allow comprehensive primary healthcare based on an understanding of the social determinants of health.

Retain and extend funding for the “Close the Gap” measures including additional support for Aboriginal Medical Services and Aboriginal Health Services.

Develop a National Aboriginal and Torres Strait Islander Social Determinants of Health Policy as a key strategy in closing the gap and overcoming Indigenous disadvantage. The policy needs to describe the social determinants, focus on social inclusion and support the provision of real opportunities in education, employment and health status, with funding tied to delivery of outcomes.  While retaining current levels and build in future growth of funding for the “Close the Gap” measures.

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE) 
Ensure access to high quality services for all Australians irrespective of who they are and where they live.

Lewis Kaplan CEO General Practice NSW
Make the social determinants of health the primary driver of health budget allocations.

Anonymous medico
Many inequalities result from poor access to services. There should be more incentives to get health professionals into areas of need.

John Mendoza, mental health advocate, Director, ConNetica Consulting Pty Ltd
Transition away from fee-for-service asap.

Linda Shields, professor of nursing – tropical health, James Cook University
Same thing. If primary health care programmes targeted at the disadvantaged were supported, then the gaps would begin to close.

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
To commit to the Australian National Preventive Health Agency agenda – philosophically, financially and in terms of services and systems.

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4. What is the single most important thing the government could do in the overall budget (ie beyond health portfolio) to tackle health inequalities?

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Publish the taxable income and tax paid by all Australian citizens.

Dr Greg Stewart, President-elect, Australasian Faculty of Public Health Medicine
Raise the dole.

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
To look at health in the broadest sense and understand the economic and social benefits of health improvement and prevention activities.  But this requires more than one activity.

For example to ensure the implementation of a comprehensive early years strategy as well as improved funding and reform of the education system to improve outcomes for poor and marginalised communities / individuals; greater access to training and employment opportunities for individuals and communities facing exclusion / disadvantage; commitment to the National Disability Insurance Scheme; funding for public transport in growth corridors; support food security in remote and urban communities; improved access to early intervention community based mental health services; programs that will use the NBN to reduce the digital divide; more secure housing for low income individuals and families.

Further work to reduce income inequality and the experience of poverty is necessary.  This would include reversing the decision to push single mothers onto Newstart and increasing the level of the Newstart allowance.

Associate Professor Heather Yeatman, president PHAA
The PHAA seeks a comprehensive approach to improving health through applying strategies (financial disincentives) known to influence behaviours positively, and at the same time raise funds for initiatives to tackle health inequalities:

TOBACCO REVENUE: Cigarette prices in Australia are lower than in some comparable countries. An increase in excise duty of ten cents per stick would reduce smoking and raise approximately $1.25 billion.

ALCOHOL TAXATION: Projected savings of $849 million if a volumetric tax is applied to wine and the WET rebate abolished.

JUNK FOOD: Implement a tax/levy on selected nutritionally undesirable foods (such as sugary soft drinks), using the funds raised for preventive programs and to promote and subsidise nutritionally desirable foods for disadvantaged groups.

LOWER CARBON USAGE: Build on the range of taxes and revenues so far introduced to lower carbon usage.

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE)
Increase Newstart Payments.

Lewis Kaplan CEO General Practice NSW
Create a single, accountable health care and disease prevention system with priority given to primary health care – this would mean educating the public too as to why acute care needs to be re-thought.

Anonymous medico
There is an association between unemployment and ill health. While overall unemployment is reported to be low, there are areas/ages of high unemployment, which should be addressed.

Linda Shields, professor of nursing – tropical health, James Cook University
Make health a federal priority and remove it from the states (yes, I know – hell will freeze over because of states’ rights etc).

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
To commit to quality education for all.  The Gonski Review partly deals with this, but it is still my belief that part-funding private education (as the Government does) is drawing money away from services for the most needy children and families.

I cannot understand public subsidizing of private education (or private healthcare for that matter) – if parents want private education for whatever reason, they should pay for it – ALL of it.  They would release public money to do what it’s there for – focus on the public system.

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5. Any advice to the media about how to cover the budget this year? What do you most want to know about it?

Vern Hughes, National Campaign for Consumer-Centred Health Care
The big public need is for long-overdue media scrutiny of budgetary handouts to provider interests in health care across private and public sectors, beginning with public funding of provider peak bodies and the role of this public funding in the formation and continuation of provider-centred health policy.

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Look at the equity impact of measures; get away from the obsession about having a surplus, please.

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
Look for investment that will reduce the rate of growth in health spending, rather than perpetuate the sometimes inefficient investment in the acute settings – when early intervention and more coordinated care will result in cheaper and better health outcomes.

Given the political environment and the likely change of Government what is the Opposition’s proposed approach to the infrastructure that has been developed in recent years (Medicare Locals, Australian National Preventive Health Agency, the Organ and Tissue Authority, the Health Workforce Agency, local health networks etc) that seek to improve system planning and performance.  What is their commitment to funding prevention and health promoting work?

Associate Professor Heather Yeatman, president PHAA
Where will the cuts be made in health?

What effort is made to take a LONG TERM VISION?

Is there any attempt to deal with the COST SHIFTING of jurisdictions such as Queensland and South Australia that are removing so much of their prevention and primary care resources and arguing it is the responsibility of the Medicare Locals?

Elizabeth Harris, Senior Research Fellow, Centre for Health Equity Training Research and Evaluation (CHETRE)
Establish a ” truthometre” that assessed assertions/ commentary made by all parties for truthfullness and make his transparent and easy to access. (Note from Croakey to readers – see the new PolitiFact initiative).

Lewis Kaplan, CEO General Practice NSW
Stop focussing on hospital waiting lists and address the reason why they exist, which is poorly integrated primary health care and inadequate national prevention programs coupled with inadequate policy on health promotion e.g. alcohol and obesity, exercise and diet.

Anonymous medico
I would like to know about the policies, not the politics!

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6. Where could savings be made in the health portfolio?

Vern Hughes, National Campaign for Consumer-Centred Health Care
A shift from a provider-centred health system to a consumer-centred health system would involve removal of failed service coordination programs that attempt to connect fragmented providers; abolition of Medicare Locals; removal of subsidies to practitioner training programs; removal of capital and block funding grants to hospitals; and removal of public funding of industry peak bodies in public and private sectors.

A/ Prof Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW
Remove the subsidy for private health insurance

Associate Professor Mark Wenitong,
 Public Health Medical Advisor
Apunipima Cape York Health Council, School of Public Health, Tropical Medicine and Rehabilitation Sciences 
James Cook University, Cairns
I think there are real savings to be made in well considered across portfolio strategic program funding to address health inequality, (and CONGRESS/NHLF is the structure to support this from Aboriginal and Torres Strait Islander perspective, and it supports real Aboriginal and Torres Strait Islander leadership).

Dr Greg Stewart, President-elect, Australasian Faculty of Public Health Medicine
Eliminate the private health insurance rebate completely

Gail O’Donnell and Lyn Morgain, Healthwest Partnership
PBS.

Ongoing focus on ensuring that the price that the Australian government pays for both patent protected and generic medicines reflects the international market and that particular points of the delivery system (such as pharmacists) are not achieving reimbursement for services which do not reflect cost of service or a high risk profile.

Health workforce reform.

Focussing health care professionals at the ‘top of their scope of practice’ requires recognition of the diversity of health care roles across the spectrum and also allows care/ interventions to be delivered at the lowest workforce cost. Currently decisions around the location of treatment are based on professional boundaries which were designed over the course of the last century and show little resemblance to either a modern risk / clinical governance approach or indeed any assessment of best outcomes for clients / consumers.

The need for a systems approach that accounts for the linkages between all parts of the service and support systems (regardless of funder) has never been more apparent.  In seeking to promote better health outcomes, increase the effectiveness of services and seek to reduce the rate of growth of health spending this interface is an area that has been consistently overlooked.

There is a growing body of evidence that the single greatest efficiency that could be made to the health budget is to move (where clinically appropriate) from high cost, high tech acute care settings to lower cost, community based primary care.  However despite this knowledge this systems approach continues to be undervalued.

Associate Professor Heather Yeatman, President PHAA
Rather than savings in federal health, we should be looking at the revenue raising side (see question 4).

Associate Professor Jan J Barendregt, School of Population Health, University of Queensland
As we reported in 2010 in our ACE-Prevention results, and in journal articles since, Australia pays far too much for cardiovascular disease prevention, due to a combination of missing out on the most efficient interventions, and paying too much for generic drugs.

Mandatory salt limits in food is very cheap, but is not being pursued.

Pharmac in New Zealand pays only a fraction of what we do for some very much-used generic drugs.

We went out of our way to make these results known in policy-making circles, and are frankly baffled by the complete lack of response. Why do policy makers keep wasting taxpayers’ money while the facts are known to them?

Lewis Kaplan, CEO General Practice NSW
Savings – not this time – it’s critical that the nation invest strongly in its future health via prevention and integrated primary health care or we will go broke.

Anonymous medico
Stop the federal-state cost shifting. Greater use of generic medicines.

John Mendoza, mental health advocate, Director, ConNetica Consulting Pty Ltd
$1billion per annum from reducing DOHA from 6000+ to 600 staff in a policy ministry for starters. Then tackle PBS, MBS issues.

Dr Peter Arnold, retired GP
I have been singing from the same song-book since 1973, when I was so publicly opposed to universal benefits (as being introduced by Medibank) and when I argued unsuccessfully in favour of selective benefits – aimed at those who needed them (pooh-poohed by Bill Hayden and his advisers because people would feel ‘stigmatised’). Today, my attitude has become commonplace, with its own jargon: “middle-class welfare”.

The answer to your question is simple – targeted (selective benefits). Taxpayers should not be funding the health care of the affluent – neither through Medicare nor through government’s propping up of private health funds. You want savings – here they are!

Professor Paul Ward, Head, Discipline of Public Health, School of Medicine, Flinders University
Bureaucracy!!!!!!

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BUT…Was Croakey asking the wrong questions?

Ian McAuley, lecturer in public sector financing, Canberra University
I’d find these questions easier to answer if the word “budget” were left out.

The budget is simply a set of appropriation bills.  The policies on which those appropriations should have been developed and articulated over many years.

But the budget has morphed into the major statement of government policy. Fiscal considerations drive policy, rather than the other way around.  Instead of considering what is needed and then finding how these needs can be funded, funding drives policy.  The budgetary process is one in which revenue is taken as a “given”, as are most pensions and other personal transfers, and all program portfolios have to accommodate their programs into what is left over.

Some would say that this leads to worthwhile expenditure restraint. But it also leads to cost shifting.  In health care costs get shifted on to consumers with co-payments and private health insurance is called on to do the a job which taxation and Medicare do much better.

So what would I like to see?  A health policy, rather than a set of fiscal projections. Funding is important, of course, but funding considerations should be about all sources of funding, instead of the current narrow focus on that funding which passes through the budget.

How can we structure co-payments so that they send appropriate price signals without not discouraging useful therapy?  How can we fund private hospitals without having them linked to private insurance?  How can we control the moral hazard which results when services are free at the point of delivery, be that because of Medicare or private insurance?  How can we phase out private health insurance as we have done with other high cost industries such as clothing and footwear?

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More reading on the Budget and health

• Jennifer Doggett recently compiled this very useful overview of the federal budget submissions from peak health and social welfare group. Increased action on prevention, the social determinants of health, Indigenous health, primary care, and consumer engagement were high on the list of priorities.

• John Menadue suggests tackling increases in medical servicing, especially in pathology and radiology.

• Australian Drug Law Reform Foundation president Dr Alex Wodak suggests better use of the funds currently spent on law enforcement of illicit drugs policy.

• The St Vincent de Paul Society calls for an increase in the Newstart allowance.

Yes, suggests Dr Melissa Stoneham of the Public Health Advocacy Institute WA (PHAIWA). In the latest edition of JournalWatch, she reviews a recent study investigating the impact of such a scheme in Montreal.

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On your bike!! Why we need more bike share schemes

Melissa Stoneham writes:

Brisbane has one….Melbourne has one…Barcelona has one…..London has one…New York is getting one….

Bike share schemes are popping up all around the globe. In fact, if you visit this site you can actually locate any bike share scheme in the world.

Bike ownership is increasing in Australia, with half (50%) of all Australian households having at least one working bicycle kept at their home. With this in mind, it is timely to consider how to better advocate for more bike share schemes in Australia.

The health benefits of riding a bike are obvious, and they seem to outweigh the risks of other metropolitan hazards such as collisions, pollution and road rage.

Recent data models on cycling in the Netherlands and Barcelona concluded that the benefits from the physical activity of cycling outweigh the combined hazards of traffic accidents and inhaling toxins.

Bike share schemes not only reduce congestion, but make it easier to access a bike in the city.

Interestingly the City of Melbourne is currently trialling free helmets with their bikes to overcome the barrier of “bringing your own helmet” or “hiring one at a local shop”.

To get a better handle on the potential public health benefits of bike-share systems, a group of Canadian researchers led by Daniel Fuller recently evaluated the ridership effects of Montreal’s bike share program, BIXI.

In the March 2013 issue of the American Journal of Public Health, Fuller and colleagues report that if you build a scheme, the riders will come.

BIXI is an acronym that stands for BIcycle-taXI.  The scheme was launched in May 2009 and by 2011, it was the largest bike share scheme in North America.

Fuller and colleagues state the scheme increases accessibility to cycling by making available at low cost, 5050 bicycles throughout 450 bicycle docking stations located in Montreal’s central and more urbanised neighbourhoods. Bicycles are available for hire hourly (the first 30 mins are free), daily, monthly and for an entire season.

The authors tracked rates of cycling in the city at three points in the BIXI timeline. These included at the launch in May-June 2009, after its first season in late 2009, and after its second season in late 2010. A self-report phone survey of approximately 700 inner city residents was conducted seeking information about their cycling activity. Data were collected on total bike riding (commute-related and recreational) in the previous week, noting whether or not a person had cycled for at least 10 minutes.

The authors controlled for seasonality and found that exposure to a BIXI station was associated with a significant increase in the likelihood of bike riding.

After the first season of BIXI there was a slight positive trend, but nothing measurable. However, by the end of the second season, Montreal’s residents who lived near a bike-share docking station were much more likely to be users of the scheme and and more likely to report using BIXI for recreational cycling than for utilitarian (eg getting to work) cycling.

A number of limitations were acknowledged, including the inability to include mobile phones in the self report survey, potentially excluding larger number of younger respondents, media campaigns promoting cycling and physical activity and some minor infrastructure additions and expansions to the city’s bike scheme.

Despite all these factors, this study still indicated that the BIXI public bicycle share program in Montreal was associated with greater likelihood of cycling after the second season of implementation for respondents exposed to the BIXI program. The study adds to the growing consensus that built environment interventions can result in population-level behaviour change.

Around the world, share bike schemes bring convenience and less congestion to city streets, while introducing people to the joys and health benefits of cycling.

We have the right to the same opportunities in Australia, and should continue to advocate for such schemes – but the question for us here in Australia is: should bike scheme riders be exempt from wearing helmets?

I will just push those worms back into the can and leave that discussion for another day.

• Dr Melissa Stoneham is Deputy Director, Public Health Advocacy Institute WA

• Impact Evaluation of a Public Bicycle Share Program on Cycling: A Case Example of BIXI in Montreal, Quebec. Daniel Fuller, Lise Gauvin,  Yan Kestens, Mark Daniel, Michel Fournier, Patrick Morency and Louis Drouin. American Journal of Public Health. Vol 103; Issue 3; Pages e85-e92.

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About JournalWatch

The Public Health Advocacy Institute WA (PHAIWA) JournalWatch service reviews 10 key public health journals on a monthly basis, providing a précis of articles that highlight key public health and advocacy related findings, with an emphasis on findings that can be readily translated into policy or practice.

The Journals reviewed include:

• Australian & New Zealand Journal of Public Health (ANZJPH)
• Journal of Public Health Policy (JPHP)
• Health Promotion Journal of Australia (HPJA)
• Medical Journal of Australia (MJA)
• The Lancet
• Journal for Water Sanitation and Hygiene Development
• Tobacco Control (TC)
• American Journal of Public Health (AMJPH)
• Health Promotion International (HPI)
• American Journal of Preventive Medicine (AJPM).

These reviews are then emailed to all JournalWatch subscribers and are placed on the PHAIWA website. To subscribe to Journal Watch go to http://www.phaiwa.org.au/index.php/other-projects-mainmenu-146/journalwatch

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PHAIWA is an independent public health voice based within Curtin University, with a range of funding partners. The Institute aims to raise the public profile and understanding of public health, develop local networks and create a statewide umbrella organisation capable of influencing public health policy and political agendas. Visit our website at www.phaiwa.org.au

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Previous JournalWatch articles:

• On big food, unhealthy partnerships and the health benefits of regulation

• Investigating the health costs of car commuting

• Time for another Sid the Seagull?

• Tackling the unhealthy food supply in disadvantaged communities

• Smoking at the movies, a global public health concern

• Sports clubs are winners when alcohol sponsorship is dropped

• Call for more research and planning to deal with public health challenges of mega events

• Environmental factors that promote cycling

• A focus on the corporate practices that contribute to poor health

• How much healthy food is sold at fast food restaurants?

• Why the world needs a dengue day

• Germany’s role in undermining tobacco control

The suggestions include taking time to develop trust and relationships (including with community members outside of the health sector), recruiting Aboriginal staff, and engaging patients and communities through art and social media.

The NHMRC-funded Gomeroi gaaynggal program recruits Aboriginal women in early pregnancy and monitors their health and that of their infants throughout pregnancy.  It aims to promote the early detection, diagnosis and prevention of diabetes and kidney disease.

Work began on setting up the program in 2006, recognising that many Aboriginal women are deeply mistrustful of mainstream pregnancy-related healthcare services, and this contributes to low uptake of antenatal care.

Thanks to Lynsey Brown from the Primary Health Care Research and Information Service (PHC RIS), for reporting on a recent article about the program in the journal, Rural and Remote Health.

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Sharing some strategies that work for Aboriginal health

Lynsey Brown writes:

Based on their experiences in Walgett (NSW) and other regional, rural and remote Aboriginal communities, Dr Kym Rae and colleagues describe strategies to improve recruitment and retention of Aboriginal people in research and antenatal programs.

The lessons learnt stem from the NHMRC-funded Gomeroi gaaynggal program, which investigates health issues across pregnancy and the post-natal period.

The Gomeroi gaaynggal team also works in partnership with the Aboriginal community and a range of health service providers to deliver an ArtsHealth program that addresses health literacy and service use.

The authors describe key strategies for recruitment and retention that can be applied across diverse regions.

Promoting both ownership and engagement, they note how community consultation must occur across multiple levels. For example, when establishing a health service, it is important to include conversations with not only health professionals but also organisations and individuals working in different areas across a range of social determinants of health (eg, housing, education, justice system), and particularly engaging with local community Elders.

It is this open and trusting dialogue that enables partnerships between researchers, clinicians and communities.

Community consultation is a step towards building trust, which is necessary between researchers and the community, and between research teams and partner organisations. However, trust takes time.

The authors describe prioritising recruitment of Aboriginal staff to enable open discussions, friendships and a supportive mentored environment, which helps this trust and sense of collaboration to develop.

The use of new technologies (in areas with adequate internet connectivity) is also discussed in detail. Social media such as Facebook can be beneficial in establishing connections, maintaining contact, keeping up-to-date with developments, providing opportunity for private emails, and encouraging communication at less cost than a phone call.

The importance of addressing local needs is emphasised, with the authors identifying successful recruitment and retention strategies in different areas.

For regional areas, provision of food and transport vouchers reduces costs for families travelling to health services. Further, Aboriginal staff spend time liaising closely with community members and health services staff.

In rural areas arranging transport and improving local access to services are key strategies. Facebook is also particularly valuable in promoting connection between the program and participants in this space.

Additionally, the authors highlight the benefits of requesting details of three contact people for each participant, to enable connection with families who often change residences.

In the remote region, the key factor is collaboration between the research team and the local Aboriginal Medical Service – with co-located offices and matching uniforms promoting an ongoing partnership.

Despite centres in different locations determining their own approach, it seems the generated strategies are applicable to other health professionals working to close the gap.

 • Lynsey Brown is Research Associate, PHC RIS

• Rae K, Weatherall L, Hollebone K, Apen K, McLean M, Blackwell C, et al. (2013). Developing research in partnership with Aboriginal communities – strategies for improving recruitment and retention. Rural and Remote Health 13: 2255. (Online)

This article, which can be accessed at http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=2255, features in the 11 April 2013 edition of PHC RIS eBulletin, available at http://www.phcris.org.au/publications/ebulletin/index.php.

The eBulletin is designed to inform readers of recently published articles and reports, news items, media releases, upcoming conferences and courses, research grants, scholarships and fellowships, PHC RIS products and services and relevant websites in the primary health care field. Those interested in receiving the weekly eBulletin are invited to subscribe to the free service at http://www.phcris.org.au/mailinglists/index.php.

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Previous PHCRIS columns at Croakey

• Reduced access to GPs for low SES consumers: Canadian study 

• The uncertain merits of pay for performance funding systems

• The impact of dementia on couples and a plan for more equitable healthcare

 • Could this approach help make integrated care a reality?

• From nurse prescribing to an Australian experiment

• Some Canadian lessons on primary health care reform and facing up to dilemmas of public health advocacy

• Patients with chronic conditions value the sense of control they gain from using complementary and alternative medicines; and five suggestions for how primary health care researchers can boost global health

• Wrapping three articles on: improving organisation of services, caution on smartphone use, nurse practitioners in primary care

• How best to improve management of childhood obesity and related health problems

• Sustaining small rural primary health care services

• What is the evidence on knowledge translation strategies?

• Should your doctor be asking after your pet too?

• Nurses add value to chronic disease management

• For patients to play a more active role in managing chronic health conditions, some changes are needed

• Some useful tips for finding health policy information on the web

• Pros and cons of telehealth for people in rural areas

• What helps GPs provide better mental healthcare (and what doesn’t)

• Improving collaboration in diabetes care

• Improving dementia management in general practice

• Pets and what they do for our health

• Improving the diagnosis of ovarian cancer

• Chronic health problems and depression

• Helping older patients with chronic diseases to navigate the health system

• Tackling overuse of antibiotics

• When doctors prescribe exercise, does it make any difference?

• Caring for country is also good for Aboriginal people

• The perils of surrogate markers

• Are Australians willing to pay more for better oral health?

• What helps encourage self-care for those with chronic illness?

• More effort needed to strengthen shared care for people with serious mental illness